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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Pagel 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 195366 <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/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804431 78339953-UT 5/30/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root_ - B45438 5/13/2021 <br /> VMI - 4552 10/27/2021 <br /> Ill. RESULTS OF TESTING It SERVICING <br /> Indicate and attach the following reports if the monitoring equipment is capable of generating either. <br /> X MonitoringSystem Set-up ❑X Alarm HistoryReport <br /> Y N NA <br /> Was any monitoring equipment replaced? ❑ ❑X El <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? ❑X 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 /> JUN 4 3 2020 <br /> E(\!N IRONM NITALHEAL-�H <br /> DEry_.. . . fi.. <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 verify that this information and the site plan showing the layout of UST system is corn tete 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 />