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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation 5a Repair ❑ 12 Month <br /> 1 . FACILITY INFORMATION <br /> cERs ID 10407034 Certification Date <br /> 4/18/25 <br /> Facility Name PILOT 618 <br /> Facility Address City RI PON ZIP Code <br /> 1501 N. JACK TONE ROAD 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> JONES COVEY GROUP, INC. 888-972-7581 <br /> Mailing Address 9595 L U CAS RANCH RD. #100 <br /> Service Technician Performing Test <br /> MITCHELL KLOSTERMANN <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICC Number Certificate No. 10191396 ICC Expiration Date <br /> 4/23/26 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VEEDER-ROOT - ID: 00003376 5/28/26 <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 Date Total # of Pages <br /> Mitchell Klostermann 4/18/25 <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 />