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UNDERGROUND STORAGE TANK MONITORING SYSTEM CERTIFICATION FORM ( Page 1 of 6) Fagenifcy orm must be used to document testing and servicing of underground storage tank ( UST) monitoring equipment. A copy form must be provided to the UST owner or operator. The owner or operator must submit a copy of this form to the local re ulatin theUSTs within 30 days of the date of the monitoring system certification . I . FACILITY INFORMATION CERS ID Date of Monitoring System Certification 10184349 1 4/23/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Building # Pilot Flying J 617 Lodi Business Site Address City ZIP Code 15100 N . Thornton Road Lodi 95242 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of Company Performing the Certification Phone # Jones Covey Group Inc . ( 888 ) 972 - 7581 Mailing Address 9595 Lucas Ranch Rd # 100 Rancho Cucamonga Ca , 91730 Name of UST Service Technician Performing the Certification (Print as shown on the ICC Certification) Jose Ochoa Contractor / Tank Tester License If ICC Certification # ICC Certification Expiration Date 804431 8004551 - UT 12/27/2019 Monitoring System Training and Certifications List all applicable certifications. Expiration Date Veeder- Root - B35931 11 /8/2019 VMI - 3032 10/27/2019 III . RESULTS OF TESTING / SERVICING Indicate and attach the following reports if the monitoring equipment is capable of generating either. Y N NA ❑X Monitoring System Set-up Alarm History Report Was any monitoring equipment replaced ? (If "Yes, " identify the specific devices replaced and list the manufacturer and model for all replacement parts in section IV below.) El M El Was damage , debris , or liquid found inside any secondary containment systems? (If "Yes, " describe what was found in section IV below.) 19 El 1:1 Is all monitoring equipment operational per manufacturer's specifications? ❑X 1:1 ❑ (If No, " describe why in section IV below.) IV. COMMENTS If directed to use this section, describe how and when the issues were or will be corrected. Tank4 STP , Tank-4 Fill Sump , And T-5 Fill Sumps Had Small Amount Of Water. Pumped Out All Water From Sumps . y T` ' IY I ,�` , h 2_ t! I _ NVlR `) NNrlEN4 `'pAM. 1 F , = I J,1 V. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the equipment identified in this document was inspected/serviced in accordance with California Code of Regulations , Title 23, Division 3 , Chapter 16 , Section 2638 and all information contained herein is true and accurate . Attached to this certification is information (e. g . , manufacturers' checklists, monitoring system set-up , alarm history report, etc .) necessary to verify that this information and the site plan showing the layout of UST system is complete and accurate . UST Service Technician Signature _ 0' CERS = California Environmental Reporting System, ID = Identification, ICC = International Code Council, Y = Yes, N = No, NA = Not Applicable