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Appendix IX <br /> Underground Storage Tank <br /> Overfill Prevention Equipment Inspection Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 12 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Inspection Date <br /> 10182131 09/19/2024 <br /> Facility Name <br /> Pilot Flying J 618 Ripon <br /> Facility Address City ZIP Code <br /> 1501 N. Jack Tone Rd. Ripon 95366 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Inspection Phone <br /> Jones Covey Group, Inc. (888) 972-7581 <br /> Mailing Address9595 Lucas Ranch Road #100, Rancho Cucamonga, Ca 91730 <br /> Service Technician Performing Inspection <br /> Shawn Rodriguez <br /> F <br /> ntractor/Tank Tester License Number <br /> tractor#804431 /Tank Tester#17-1766 <br /> ICC Number Expiration Date <br /> 8412602 11/19/2024 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder-Root#1347358 02/09/2025 <br /> Phil-Tite#1021753712 12/01/2024 <br /> 4. INSPECTION PROCEDURES INFORMATION <br /> Inspection Procedures Used Components Inspected <br /> PEI-1200 T1:DIESEL, T2:DIESEL, T3:DIESEL, and T6:AUTO DIESEL drop tubes. <br /> PEI-1200 T1:l3io, T2:Unleaded, and T3:Premium drop tubes. <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING INSPECTION <br /> I hereby certify that the OPE was inspected in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.2; 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 /> 09/19/2024 47 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council, OPE = Overfill Prevention Equipment <br /> Page 1 of 2 <br />