Laserfiche WebLink
Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair [2 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182131 5/18/2021 <br /> Facility Name <br /> Pilot Flying J 618 Ripon <br /> Facility Address City ZIP Code <br /> 1501 N. Jack Tone Road Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Jones Covey Group 888-972-7581 <br /> Mailing Address 9595 Lucas Ranch RD. Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Robert Bramhall <br /> Contractor/Tank Tester License Number <br /> 804431 <br /> ICC Number ICC Expiration Date <br /> 8206958 6/28/2021 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> �OPW 104444 01/12/2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used I Components Tested <br /> Hydrostatic Testing for one Hour- PEI-1200 BIO Fill Sump <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; 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 /> r <br /> ervice Technician Signature Date Total # of Pages <br /> u 5/18/2021 20 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />