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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 10182131 Test Date <br /> 05.18.2022 <br /> Facility Name <br /> Pilot Flying J 618 <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 Inc. (888) 972-7581 <br /> Mailing Address 9595 Lucas Ranch Road #100, Rancho Cucamonga, CA 91730 <br /> Service Technician Performing Test <br /> Justin Zorn <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICC Number ICC Expiration Date <br /> ICC -9157862 02.12.2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Phil-Tite - 1016003711 12.04.2022 <br /> OPW-0177855 04.02.2023 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200-Hydrostatic test for 1 Hour T1 Diesel OPW Spill Bucket <br /> PEI 1200-Hydrostatic test for 1 Hour T2 Diesel Phil-Tite Spill Bucket <br /> PEI 1200-Hydrostatic test for 1 Hour T3 Diesel Phil-Tite Spill Bucket/T6 AUTO DSL OPW Spill Bucket <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 /> Service Technician Signature Date Total # of Pages <br /> 05.18.2022 34 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />