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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Repoli Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 2 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10184349 07/17/2025 <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 /> .lanes 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 /> Justin Zorn <br /> Contractor/Tank Tester License Number <br /> 804431 A, B HAZ <br /> ICC Number I ICC Expiration Date <br /> ICC _9157862 02/11/2027 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> INCON Level 4- 1016003711 04/04/2027 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI 1200 All LIST Secondary Lines <br /> PEI 1200 All UST Containment Sumps <br /> PEI 1200 All LIST Under Dispenser Containments <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> 1 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. 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 /> 07/17/2025 20 <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 />