Laserfiche WebLink
Appendix V1 <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION I[o Installationf Repair 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certiflr-ation Date <br /> 10182131 05/1312025 <br /> Facility Name <br /> Pilot F In g J 618 Ripon Auto/Truck TLS-M <br /> Fedilty Address city ZIP Code <br /> 1501 N. Jack Tone Road Ripon 195366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the certification Phone <br /> Jones covey Group, Inc. (888) 972-7581 <br /> Mailing Address <br /> 9595 Lucas Ranch Road #100, Rancho Ducarnonga, CA 91730 <br /> Service Techniclan Performing Test <br /> Shawn Rodriguez <br /> Contractor/Tank Tester Lioense plumber <br /> Contractor#904431 1 Tank Tester#17-1766 <br /> ICC Number ICC Expiration Date <br /> 8412602 10122I2026 <br /> 3. TRAINING" AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root #E47358 02J1412027 <br /> Real Jacket#B473SB 021 t 712027 <br /> VMl9482 10125 026 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> l hereby c Hf(that fhe mans o►ing system is operatlonal In accordance with Cafflbmb Code <br /> of Regulations, fide 23, division 3, chapter 16, secHon 2638; that required supporting <br /> docrrrrrentedon Is attached; and afl Informatlan contained herein is accurate. <br /> Service Technician Signature Date Total # of Pages <br /> 05/1312025 22 <br /> ERS = Calftrinia Environmental Reporting System, GPH = Gallons Per Hour, ID = Iden0cation, <br /> [CC = IntemartioneI Code Council, LLD = Line Leak Detector, NA = Not Applicable, SW = Single- <br /> Walled, UDC = Under-Dispenser Containment, UST = Underground Storage Tank. <br /> VPH = Va uumffl ssurelHydrosta#ic <br /> Page 1 of 6 <br />