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MONITORING SYSTEM CERTIFICATION For Use By All Jurisdictions Within the State of California 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): 91 System set-up ki Alarm history report Arturo Perez -� -- Technician Name (print): Signature: Certification No.: 838509 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 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 LIST systems within 30 days of test date. A. General Information FI Pilot - In J #618 Facility Name: y 9 Bldg. No.: Site Address: 1501 North Jack Tone Road City: Ripon Zip: 95366 Facility Contact Person: Darren Thomas (Frazenhill) Contact Phone No.: 20( 9 1 559-4141 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 appropriate boxes to indicate s ecific a ui ment insl iected/serviced: Tank ID: Vent Box Tank ID: Bio -Shed sump ya In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Piping Sump / Trench Sensor(s). Model: 794380-2051794380-304 47 Piping Sump / Trench Sensor(s). Model: 794380-2081794380-304 ❑ 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 (seecify 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: TLM Sump Tank ID: North Transition Sump ❑ In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: ❑ Annular Space or Vault Sensor. Model: ❑ Annular Space or Vault Sensor. Model: )G Piping Sump / Trench Sensor(s). Model: 794380-208[794380-304 )o Piping Sump / Trench Sensor(s). Model: 794380-2081794380-304 ❑ 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 a ui ment tyee and model in Section E on Pae 2). ❑ Other (seecify a ui ment tyee and model in Section Eon Pa e 2 . 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 Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: Dispenser lD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). enser Containment Floats and Chains . ❑ Dis enser Containment Floats and Chains . penserlD: DispenserlD: LDis 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 Chain(s). If 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): 91 System set-up ki Alarm history report Arturo Perez -� -- Technician Name (print): Signature: Certification No.: 838509 License. No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.:(888 972-7581 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