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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION ❑ Installation r] Repair ❑ 12 Month <br /> 1. FACILITY INFORMATION <br /> CEFS ID Certification Date <br /> 10/82131 051131 025 <br /> Facility Name <br /> Pilot Flyins J 618 Ripon Bio TL -350 <br /> Facility Address city ZIP Corte <br /> 1501 N. ,lack Tone Road Ripon 195366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> ,Jones Covey Group, Inc. (888) 72-7581 <br /> Mailing Address <br /> 9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br /> Service Technician Perl`orming Test <br /> Shawn Rodriguez <br /> Contractor/Tank Tester license NUMber <br /> Contractor#804431 f Tank Tester #17-1766 <br /> ICC Number ]CC Expiration Bate <br /> 8412602 101221202E <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Feeder-Root#847388 0211412027 <br /> Red Jacket#847358 021/712027 <br /> VMI ##4822 10l2512026 <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 2 38; that required supporteng <br /> documentation is attached; and afl information contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 10511312025 18 <br /> CE IRS = California Environmental Reporting System, G PH = Gallons Per Hour, ID = Identification, <br /> ICC = Intemationai Cade Cooncll, LLD = Line Leak Defector, NA = Not Applicable, SW = Sing le- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank, <br /> VPH = Vacuum/Pressure/Hydrostatic <br /> Page 1 of 6 <br />