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UNDERGROUND STORAGE TANK <br /> MONITORING SYSTEM CERTIFICATION FORM (Page I 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 /> 10184349 4/15/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) Building# <br /> Pilot Flying J 617 <br /> Business Site Address City ZIP Code <br /> 15100 N. Thornton Road I Lodi 195242 <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 /> Jose Ochoa <br /> Contractor Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804431 8004551-UT 10/28/2021 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder-Root - B35931 11/7/2021 <br /> VMI - 3032 10/3/2021 <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? <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 /> (!f"Yes."describe what was found in section IV below.) <br /> Is all monitoring equipment operational per manufacturer's specifications? <br /> (!f"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 /> Replaced L-5 (794380-208) Like For Like In Transition Sump-1. Also L-11 Fuel Alarm Not Able To Clear Alarm Due To <br /> Missing Floats On Probe. Will Order And Return. <br /> R E <br /> klk 0 )' 2020 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <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 LIST system is complete and accurate. <br /> UST Service Technician Signature /1 <br /> CERS=California Environmental Reporting System,ID=Identification,ICC=Intemational Code Council,Y=Yes.N=No,NA=Not Applicable <br />