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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation [2 Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10182131 04/06/2023 <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 <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 /> 804431 A, B HAZ <br /> ICC Number ICC Expiration Date <br /> 8412602 �11/19/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON Level 4 Sump Tester- 1021753712 12/6/2024 <br /> Veeder-Root- B47358 02/09/2025 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-1200 / Incon - Hydrostatic T1-Dsl STP, T4-87 STP, T5-91 STP, T6-AutoDsl STP, UDC 14-15, and UDC 26M. <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I 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 /> V04/06/2023 18 <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 />