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LI Appendix VI JUN 0 12016 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 Facility Name: Pilot-Flying J#617 Bldg.No.: Site Address: 15100 N.Thornton Rd. City: Lodi Zip: 95242 Facility Contact Person: Manager Contact Phone No.:(209 ) 339-4066 Make/Model of Monitoring System: TLS 350 Date of Testing/Servicing: 0 5 / 03/ 2 0 1 6 B. Inventory of Equipment Tested/Certified Check thea ro riate boxes to indicatespecific a ui ment inspected/serviced: Tank ID: T5 91 12K Tank ID: 7°❑ In-Tank Gauging Probe. Model: 847390-107 ❑ In-Tank Gauging Probe. Model: X47 Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: A❑ Piping Sump/Trench Sensor(s). Model: 794380-208 ❑ Piping Sump/Trench Sensor(s). Model: )❑ Fill Sump Sensor(s). Model: 794380-208 ❑ Fill Sump Sensor(s). Model: )CI Mechanical Line Leak Detector. Model: Fe Petro STP MLD-HC ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: a❑ Tank Overfill/High-Level Sensor. Model: Phil-rite Flapper ❑ 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: Tank ID: ❑ 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: ❑ Piping Sump/Trench Sensor(s). Model: ❑ 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. ❑ Others ecif e uiment t e and model in Section E on Pae 2). Dispenser ID: 13 Dispenser ID: 14-15 C Dispenser Containment Sensor(s). Model: 794380-208 C Dispenser Containment Sensor(s). Model: 794380-208 )E] Shear Valve(s). 11 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: 16-17 Dispenser ID: 18 I Dispenser Containment Sensor(s). Model: 794380-208 1❑ Dispenser Containment Sensor(s). Model: 794380-208 JO Shear Valve(s). U Shear Valve(s). ❑ D'senser Containment Floats and Chains. ❑ Dis enser Containment Floats and Chain(s). DispenserlD: DispenserlD: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). ❑ Dis enser Containment Floats and Chains ❑ Dispenser 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,1 have also attached a copy of the report;(check all that apply): f_r]System set-up JD Alarm history report Issac Garcia � — Technician Name(print): Signature: Certification No.: 842806 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 / 3 / 2 0 1 6 Monitoring System Certification Page of 12/07