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0 Appendix VI 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 Pilot Flying J 617 Facility Name: y g Bldg.No.: Site Address: 15100 N Thornton Rd City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.: 20( 9 ) 339-4066 Make/Model of Monitoring System: TLS-350 Date of Testing/Servicing: 0 5 / 15/ 2 0 1 4 B. Inventory of Equipment Tested/Certified Check the aeeroeriate boxes to Indicates ecific equipment ins ected/serviced: Tank ID: T187 20K Tank ID: T2 e7 20K K- In-Tank Gauging Probe. Model: 846390-109 KI In-Tank Gauging Probe. Model: 846390.109 Annular Space or Vault Sensor. Model: 794380-303 )c Annular Space or Vault Sensor. Model: 794380-303 >c Piping Sump/Trench Sensor(s). Model: 794380-208 C Piping Sump/Trench Sensor(s). Model: 794380-208 PC Fill Sump Sensor(s). Model: 794380-208 C Fill Sump Sensor(s). Model: 794380-208 ,e Mechanical Line Leak Detector. Model: N/A ,d7 Mechanical Line Leak Detector. Model: VMi LD3000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: N/A ,e- Tank Overfill/High-Level Sensor. Model: OPW Flapper valve d❑ Tank Overfill/High-Level Sensor. Model: OPW Flapper valve ❑ Other s eci equipment t e and model in Section E on Pae 2). ❑ Others ci a ui ment tyee and model in Section E on Pae 2). Tank ID: T3 87 20K Tank ID: T4 87 20K )- In-Tank Gauging Probe. Model: 846390-109 9-1 In-Tank Gauging Probe. Model: 846390-109 :c Annular Space or Vault Sensor. Model: 794380-303 Kj Annular Space or Vault Sensor. Model: 794380-303 ;4- Piping Sump/Trench Sensor(s). Model: 794380-208 x:i Piping Sump/Trench Sensor(s). Model: 794380-208 )C Fill Sump Sensor(s). Model: 794380-208 ;C Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: N/A ki Mechanical Line Leak Detector. Model: Fe Petro STP MLD-HC ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: NSA XC Tank Overfill/High-Level Sensor. Model: OPW Flapper valve .i] Tank Overfill/High-Level Sensor. Model: Phil-rite Flapper valve ❑ Others ci a ui ment t e and model in Section E on Pae 2. ❑ Others ci a ui ment_type and model in Section E on Pae 21. Dispenser ID: 1-2 Dispenser ID: 3A 'f. Dispenser Containment Sensor(s). Model: 794380-208 tf1 Dispenser Containment Sensor(s). Model: 794380-208 Shear Valve(s). )�.] Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chains. Dispenser ID: 5-6 Dispenser ID: 7-8 * Dispenser Containment Sensor(s). Model: 794360-208 )F1 Dispenser Containment Sensor(s). Model: 794380-208 K: Shear Valve(s). C Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chains. Dispenser ID: 9-10 Dispenser ID: 11-12 �c Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 K- Shear Valve(s). K-1 Shear Valve(s). ❑ Dis enser Containment Floats and Chains ❑ Dis nser 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): ❑System set-up ❑Alarm history report Issac Garcia Technician Name(print): Signature: Certification No.: x42806 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/Servicing:0 5 / 15/ 2 0 1 4 Monitoring System Certification Page of 12/07 11 2 EL";k trm w V 0 N a V uwo JUN ft2014 ENVIRONMENTAL HSAILTIfful DEPARTMENT