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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 /> 10184349 5/28/2019 <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 Lodi 95242 <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 # rtification # ICC Certification Expiration Date <br /> 777 <br /> 804431 8004551 - UT 12/27/2019 <br /> Monitoring System Training and Certifications List all applicable certifications. Expiration Date <br /> Veeder- Root - B35931 11 /8/2019 <br /> VMI - 3032 10/27/2019 <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 Monitorin gS ystem Set-up Alarm HistoryRepor t <br /> Was any monitoring equipment replaced ? El <br /> FX1 El <br /> (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section W 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 ? F 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 /> R E <br /> E7, k <br /> r € <br /> IUP , ; C' _1019 <br /> NVIPONCeIIENT.AL I-1EAl:F11 <br /> DEPAR ENT <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 complete and accurate. <br /> UST Service Technician Signature <br /> CERS =Ca lifomia EnvironmentalR eportingSy stem, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA= N of Applicable <br />