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Appendix VI <br />Underground Storage Tank <br />Monitoring System Certification Form <br />TYPE OF ACTION ❑ Installation 0 Repair ❑ 12 Month <br />1. FACILITY INFORMATION <br />CERS ID Certification Date <br />10182131 <br />11/01/2024 <br />Facility Name <br />Pilot Flying J 618 Ripon <br />Facility Address <br />1501 N. Jack Tone Road <br />City <br />Ripon <br />ZIP Code <br />95366 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Certification <br />Jones Covey Group, Inc. <br />Phone <br />(888) 972-7581 <br />Mailing Address <br />9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br />Service Technician Performing Test <br />Shawn Rodriguez <br />Contractor/Tank Tester License Number <br />Contractor #804431 / Tank Tester #17-1766 <br />ICC Number <br />8412602 <br />ICC Expiration Date <br />10/24/2026 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Veeder-Root #847358 <br />02/09/2025 <br />VMI #4822 <br />12/07/2024 <br />OPW - 1192360 <br />06/27/2025 <br />FFS - 1021753712 <br />12/01/2024 <br />4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the monitoring system is operational in accordance with California Code <br />of Regulations, title 23, division 3, chapter 16, section 2638; that required supporting <br />documentation is attached, and all information contained herein is accurate. <br />Service Technician Signature VDate <br />11/01/2024 <br />Total # of Pages <br />22 <br />CERS = California Environmental Reporting System, GPH = Gallons Per Hour, ID = Identification, <br />ICC = International Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single - <br />Walled, UDC = Under -Dispenser Containment, UST = Underground Storage Tank, <br />VPH = Vacuum/Pressure/Hydrostatic <br />Page 1 of 6 <br />