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SWRCX,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(If 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 0500075 Date of Testing: 08/04/2008 <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: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 6 SUP SUP El ❑ ❑ ❑ Secondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 5 PLU x ❑ ❑ Secondary Pipe 1 DIE TWENTY F ❑ <br /> Secondary Pipe 5 PLU X ❑ ❑ ❑ Secondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 4 UNL Fx I ❑ ❑ PRI Secondary Pipe 1 DIE ❑ X ❑ ❑ <br /> Secondary Pipe 4 UNL ❑ ❑ ❑ Secondary Pipe 1 DIE E ❑ ❑ ❑ <br /> Secondary Pipe 1 DIE ❑ Secondary Pipe 1 DIE El ❑ ❑ ❑ <br /> Secondary Pipe 1 DIE ❑ ❑ X Secondary Pipe 1 DIE El ❑ ❑ <br /> Secondary Pipe 1 DIE ❑ ❑ Fx I Secondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 2 DIE 1:1Secondary Pipe 1 DIE ❑ F ❑ <br /> Secondary Pipe 2 DIE ❑ ❑ Secondary Pipe 1 DIE � ❑ ❑ ❑ <br /> Secondary Pipe 2 DIE ❑ 1:1 E Secondary Pipe 1 DIE El ❑ ❑ ❑ <br /> Secondary Pipe 3 DIE THIRTY ❑ ❑ El Secondary Pipe 1 DIE THIRTY ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 08/04/2008 <br />