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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California C. Certification - 1 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 in Alarm history report Technician Name (print): Arturo Perez Signature: Certification No.: 838509 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(_88� 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Seryicing: 3 / 11 / 2 0 1 6 Monitoring System Certification Page of 12/07 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 Facility Name: Pilot -Flying J #618 Bldg. No.: Site Address: 1501 North Jack Tone Road City: Ripon Zip: 95366 Facility Contact Person: Darren Thomas (Frazenhill) Contact Phone No.: 20( 9 ) 559-4141 Make/Model of Monitoring System: TLS -350 Date of Testing/Servicing: 3 / 11 / 2 0 1 6 B. Inventory of Equipment Tested/Certified Check the a ro riate boxes to indicatespecific a ui ment insi iected/serviced: Tank ID: T#1 Bio -Diesel Tank ID: T#2 - 87 Unleaded 12,000 gals )C1 In -Tank Gauging Probe. Model: 846391--109 k❑ In -Tank Gauging Probe. Model: 847390-107 Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: A] Piping Sump / Trench Sensor(s). Model: 794380-2081794380-304 ❑ Piping Sump / Trench Sensor(s). Model: 93 Fill Sump Sensor(s). Model: 794380-2081794380-304 ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: jd3 Tank Overfill / High -Level Sensor. Model: OPw Flapper valve ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Tank ID: T#3-9112,00 gals Tank ID: South Transition Sump )0 In -Tank Gauging Probe. Model: 847390-109 ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: )0 Piping Sump / Trench Sensor(s). Model: 794380-208/794380-304 ❑ Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other �specify equipment t e and model in Section E on Pae 2). ❑ Other(specify equipment t e and model in Section E on Pae 2). Dispenser lD: DispenserlD: ❑ 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 Chains . Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). Dis enser Containment Floats and Chains . ❑ Dis enser Containment Floats and Chains . penserlD: DispenserlD: r Dispenser Containment Sensor(s). Model: :Dispenser ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). ❑ Shear Valve(s). Containment Float�sj and Chains ❑ Dis enser Containment Floats and Chains . 'If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility. C. Certification - 1 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 in Alarm history report Technician Name (print): Arturo Perez Signature: Certification No.: 838509 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(_88� 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Seryicing: 3 / 11 / 2 0 1 6 Monitoring System Certification Page of 12/07