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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 /> 10184349 4/11/2023 <br /> Facility Name <br /> Pilot Flying J 617 Lodi <br /> Facility Address City ZIP Code <br /> 15237 N. Thornton Road Lodi 95242 <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 /> Keith Henderson <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICC Number ICC Expiration Date <br /> 8124725 7/10/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW- 101273 7/5/2023 <br /> FFS - 1007173708 2/3/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-1200 - Hydrostatic Test for 1 Hour T-1 thru T-4 87 Unleaded Spill Buckets <br /> PEI-1200 - Hydrostatic Test for 1 Hour T-5 Premium 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 /> 4/11/2023 33 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />