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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 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 / 13/ 2 0 1 5 B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicates ecific equipment inspected/serviced: Tank ID: T5 9112K Tank ID: X17 In-Tank Gauging Probe. Model: 847390-107 ❑ In-Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: 794380-303 ❑ Annular Space or Vault Sensor. Model: )(I 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: KI 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: 93 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 a ui ment 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 Pa e 2. ❑ Others ecif a ui ment t e and model in Section Eon Pae J2. Dispenser ID: 13 Dispenser ID: 14-15 C Dispenser Containment Sensor(s). Model: 794380-208 T1 Dispenser Containment Sensor(s). Model: 794380-208 U Shear Valve(s). 10 Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dispenser Containment Floats and Chain(s). Dispenser ID: 16-17 Dispenser ID: 18 Ti Dispenser Containment Sensor(s). Model: 794380-208 U Dispenser Containment Sensor(s). Model: 794380-208 C Shear Valve(s). U Shear Valve(s). ❑ Dispenser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ 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 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): ICI System set-up C Alarm history report Technician Name(print): Issac Garcia 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 / 13/ 2 0 1 5 Monitoring System Certification Page of 17J07 JUIN 0 9 2015 ENVIRONMENTAII.,