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Appendix VI <br /> Underground Storage Tank <br /> Monitoring System Certification Form <br /> TYPE OF ACTION El Installation ® Repair ® 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Certification Date <br /> 411 512 02 5 <br /> Facility Name <br /> Pilot Flying J 617 Lodi (Truck Side) <br /> Facility Address City ZIP Code <br /> 15237 N. Thornton Road Lodi 95242 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Certification Phone <br /> Jones Covey Group Inc. t888)972-7581 <br /> Mailing Address <br /> 9595 Lucas Ranch Road#100, Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Keith Henderson <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICC Number ICC Expiration Date <br /> 8124725 7/1612025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> VeederTEC -A24995 4/19/2026 <br /> VMI -#3248 3/17/2027 <br /> 4. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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 /> -A Aim&� <br /> 4/1512025 45 <br /> CERS = Califomia 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 />