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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-FI m J#617 Facility Name: y 9 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 / 13/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment ins ected/serviced: Tank ID: T187 20K Tank ID: Tz 87 20K In-Tank Gauging Probe. Model: 846390-109 x❑ In-Tank Gauging Probe. Model: 846390-109 Annular Space or Vault Sensor. Model: 794380-303 A] Annular Space or Vault Sensor. Model: 794380-303 )e Piping Sump/Trench Sensor(s). Model: 794380-208 A] Piping Sump/Trench Sensor(s). Model: 794380-208 A] Fill Sump Sensor(s). Model: 7943807208 >O Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: N/A C Mechanical Line Leak Detector. Model: VM1 LD3000 ❑ Electronic Line Leak Detector. Model: N/A ❑ Electronic Line Leak Detector. Model: x❑ Tank Overfill/High-Level Sensor. Model: OPw Flapper x❑ Tank Overfill/High-Level Sensor. Model: OPw Flapper ❑ Other(specify equipment t e and model in Section E on Pae 2). ❑ Other(specify a ui ment type and model in Section E on Pae 2). Tank ID: T38720K Tank ID: T48720K Al In-Tank Gauging Probe. Model: 846390-109 )0 In-Tank Gauging Probe. Model: 846390-109 tC] Annular Space or Vault Sensor. Model: 794380-303 )G Annular Space or Vault Sensor. Model: 794380-303 .f7 Piping Sump/Trench Sensor(s). Model: 794380-208 )CI Piping Sump/Trench Sensor(s). Model: 794380-208 41 Fill Sump Sensor(s). Model: 794380-208 z❑ Fill Sump Sensor(s). Model: 794380-208 ❑ Mechanical Line Leak Detector. Model: )6 Mechanical Line Leak Detector. Model: Fe Petro STP MLD-HC ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ,] Tank Overfill/High-Level Sensor. Model: OPw Flapper 0 Tank Overfill/High-Level Sensor. Model: Phil-rite Flapper ❑ Other(specify a ui ment type and model in Section E on Pae 2). ❑ Others ecif a ui ment t e and model in Section E on Pae 2. Dispenser ID: 1-2 Dispenser ID: 3-4 • Dispenser Containment Sensor(s). Model: 794380-208 n Dispenser Containment Sensor(s). Model: 794380-208 • Shear Valve(s). n Shear Valve(s). ❑ Dispenser Containment Floats and Chains. ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 5-6 Dispenser ID: 7-8 U Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 )U Shear Valve(s). U Shear Valve(s). [Dispenser Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). ID: 9-10 Dispenser ID: 11-12 Dispenser Containment Sensor(s). Model: 794380-208JE] Dispenser Containment Sensor(s). Model: 760-380-206 Shear Valve(s). U Shear Valve(s). Dispenser 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 verity 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 19 Alarm history report Issac Garcia -- - �—'`—�--�-� Technician Name(print): Signature: Certification No.: B42806 License.No.: 804431 Testing Company Name: Jones Covey Group, Inc. Phone No.: 88( 8 1 972-7581 Testing Company Address: 9595 Lucas Ranch Rd.#100 Rancho Cucamonga CA,91730 Date of Testing/Servicing:0 5 / 13/ 2 0 1 5 Monitoring System Certification Page of 12/0_Z. JUIN 0 2cf t5J VIROf s.rC"n �F- ,e�`rs��,� -