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Appendix VI JUN 0 3 2016 MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information 9 Bldg. Pilot -Flying J #618 Facility Name: Y g. No.: 1501 Site Address: 1501 N Jacktone Rd. Facility Contact Person: Manager City: Ripon Contact Phone No.: ( 209 Zip: 95366 599-4141 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 06 / 2 0 1 6 B. Inventory of Equipment Tested/Certified rhark tha anni nnriata hnxpc to inrfrrata cnw-ifir anurnmant inenaMarf/camiraA• Tank ID: T1 Bio Diesel 20K Tank ID: TLM Sump r❑ In -Tank Gauging Probe. Model: 846391-109 ❑ In -Tank Gauging Probe. Model: N/A Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: N/A )c Piping Sump / Trench Sensor(s). Model: 794380-2081794380-304 )C Piping Sump / Trench Sensor(s). Model: 794380-208/794380-304 )e Fill Sump Sensor(s). Model: 794380-2081794380-304 ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A x❑ Tank Overfill / High -Level Sensor. Model: DPW Flapper ❑ Tank Overfill / High -Level Sensor. Model: N/A ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2 . Tank ID: North Transition Sump Tank ID: South Transition Sump ❑ In -Tank Gauging Probe. Model: N/A ❑ In -Tank Gauging Probe. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A ❑ Annular Space or Vault Sensor. Model: N/A 91 Piping Sump / Trench Sensor(s). Model: 794380-2081794380-304 ap Piping Sump / Trench Sensor(s). Model: 794380-208/794380-304 ❑ Fill Sump Sensor(s). Model: N/A ❑ Fill Sump Sensor(s). Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Mechanical Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ❑ Tank Overfill / High -Level Sensor. Model: N/A ❑ Tank Overfill / High -Level Sensor. Model: N/A ❑ Other(specify equipment t e and model in Section E on Page 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser ID: DispenserID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains . ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ DiSpenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dispenser Containment Floats and Chains ❑ Dispenser Containment Floats and Chain(s). `It the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a copy of the report; (check all that apply): ® System set-up ® Alarm history report Technician Name (print): Issac Garcia Signature: �— Certification No.: 842808 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 ) 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing: 0 5 / 06 / 2 0 1 6 Monitoring System Certification Page of 12/07