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`SWRCRI January 2002 Page 1. <br /> Seconaly Containment Testing ReA For <br /> This form is intended for use by contractors perf ening periodic testing of UST secondary containnient systerns. Use the <br /> appropriate pages of this form to report results for all cornporrents tested. The completed fornr, written test procedures, and <br /> printouts.fronr tests({f applicable). should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: FLYING J 7 Date of Testing: 04/17/2006 <br /> Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 <br /> Facility Contact: JOSE Phone: (2 0 9) 599-4141 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: ANEIL CHAND <br /> Credentials: ❑CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box REGX❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box PLUS ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box PREMIUM ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box DIESEL ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box DIESEL ❑ ❑ ❑ El El ❑ ❑ <br /> Spill Box DIESEL ❑ ❑ ❑ ❑ ❑ ❑ ED <br /> Spill Box OIL/WATR ❑ (❑� ❑ ❑ El El ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was pcifonned,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of'n1v knowledge, the facts stated in this docuntent are accurate and in full compliance:with legal requirements <br /> Technician's Signature: Date: 04/17/2006 <br />