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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 52 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184349 10/28/2022 <br /> Facility Name <br /> Pilot Flying J 617 Lodi <br /> Facility Address City ZIP Code <br /> 15237 N. Thornton Rd. Lodi 95242 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Jones Covey Group Inc. (209) 339-4066 <br /> Mailing Address <br /> 9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Shawn Rodriguez <br /> Contractor/Tank Tester License Number <br /> Contractor#804431 / Tank Tester #17-1766 <br /> ICC Number ICC Expiration Date <br /> 8412602 11/13/2022 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Incon Level 4- Sump Tester#1021753712 11/18/2022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-1200 T1-T5 STP Sumps & T1-T5 Fill Sumps <br /> PEI-1200 UDC Sumps for Fueling Points 1-18 <br /> PEI-1200 87 Product Secondary, 87 Syphon Secondary,and 91 Product Secondary <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637, 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 /> 10/28/2022 22 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />