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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair [0 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10726990 <br /> 0812112024 <br /> Facility Name <br /> Pilot 1017 Lathrop <br /> Facility Address City ZIP Code <br /> 345 Roth Rd. Lathrop 95231 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Jones Covey Group Inc. (888)972-7581 <br /> Mailing Address 9595 Lucas Ranch Road#100, Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Shawn Rodriguez <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICG Number ICC Expiration Date <br /> 8412602 11/1912024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW-1192360 0612712025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 12001 Industry Standard Tank 1 &Tank 2 OPW 5 Gallon Spill Buckets <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 96, section 2637.1; that required supporting <br /> documentation is attached; and all i"nformati"on contained herein is accurate. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> 08/21/2024 28 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />