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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 52 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10184349 5-24-2021 <br /> Facility Name <br /> Pilot Flying J 617 Lodi <br /> Facility Address City ZIP Code <br /> 15237 N. Thornton Road Lodi CA 95242 Lodi 95242 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Jones Covey Group Inc. (888) 972-7581 <br /> Mailing Address 9595 Lucas Ranch Rd. <br /> Service Technician Performing Inspection <br /> Jose Ochoa <br /> Contractor/Tank Tester License Number <br /> 804431 A,B HAZ <br /> ICC Number Expiration Date <br /> 8004551-UT 10-28-2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW Cert# 100826 12-28-2021 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI-1200 - Manufacture Guidelines Tank-1 Thru Tank-5 Drop Tube With Flapper <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> I hereby certify that the OPE was inspected in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br /> documentation is attached, and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 5-24-2021 14 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />