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Appendix VIII <br /> Underground Storage Tank <br /> Spill Container Testing Repoli Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 52 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184349 <br /> 4l1512D25 <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 7/16/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> OPW- 101273 7/2/2025 <br /> FFS- 1007173708 2/13/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-1200 T-1 thru T-4 87 Unleaded Spill Buckets <br /> PEI-1200 T-5 Premium Spill Bucket <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> . 4/15/2025 g <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />