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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM Page 1 of 6) <br /> This form must be used to document testing and servicing of underground storage tank(UST)monitoring equipment. A copy <br /> of this form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local <br /> agency regulating the USTs within 30 days of the date of the monitoring system certification. <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Monitoring System Certification <br /> 10182131 5/6/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Pilot Flying J 618 <br /> Business Site Address city ZIP Code <br /> 1501 N Jack Tone Rd. Ripon t95366 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of Company Performing the Certification Phone# <br /> Jones Covey Group Inc. (888) 972-7581 <br /> Mailing Address <br /> 9595 Lucas Ranch Rd #100 Rancho Cucamonga Ca, 91730 <br /> Name of UST Service Technician Performing the Certification(Print as shown on the ICC Certification) <br /> Austin Sterling <br /> Contractor i Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804431 8339953-UT 5/30/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root - B45438 5/13/2021 <br /> VM 1 - 4552 10/27/2021 <br /> III. RESULTS OF TESTING/SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA <br /> X Monitoring System Set-up X Alarm History Report <br /> Was any monitoring equipment replaced? ❑ ❑X E] <br /> (If"Yes."identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) <br /> Was damage,debris,or liquid found inside any secondary containment systems? <br /> (if"Yes,"describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? © El El <br /> (If"No,"describe why in section IV below.) <br /> IV. COMMENTS <br /> If directed to use this section,describe how and when the issues were or will be corrected. <br /> RECEIvry`- - <br /> AUG 14 2020 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of <br /> Regulations,Title 23,Division 3, Chapter 16,Section 2638 and all information contained herein is true and accurate. Attached to <br /> this certification is information(e.g., manufacturers'checklists, monitoring system set-up, alarm history report,etc.) necessary <br /> to verity that this information and the site plan showing the layout of UST system is complete and accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=International Code Council,Y=Yes,N=No,NA=Not Applicable <br />