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SWRCB,January 2002 Page 2. <br /> Secondary Containment Testing Report Farm <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 DateofTesting: 08/04/2008 <br /> Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 <br /> Facility Contact: JOSE Phone: (2 0 9) 599-414 1 <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 License Number: 7 4 316 0 <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 /> Piping Sump 6 SUP a ❑ ❑ ❑ UDC 7/8 ❑ F-1 1:1 <br /> Piping Sump 5 PLU xEl ❑ ❑ UDC 9/10 F-71 <br /> ❑ ❑ F-1 <br /> Piping Sump 4 UNL ❑ ❑ ElUDC11/12 a ❑ I ❑ ❑ <br /> Piping Sump 3 DIE x El F-1 F-1 UDC 13 Q ❑ ❑ ❑ <br /> Piping Sump 2 DIE M'' ❑ ❑ UDC 14 ❑ ❑ <br /> Piping Sump 1 DIE F F-1 a 1:1UDC 15 ❑ ❑ <br /> Piping Sump 2 DIE ❑ a ❑ UDC 16 FRI ❑ ❑ ❑ <br /> Piping Sump 2 DIE ❑ a ❑ UDC 17 FRI ❑ ❑ ❑ <br /> Piping Sump 7 OIL X ❑ ❑ ❑ UDC fs18 x ❑ ❑ F-1 <br /> UDC 1/2 1 ❑ ❑ F-1UDC fs19 El ❑ El F] <br /> UDC 3/4 X ❑ ❑ ❑ UDC fs20 ❑ ❑ ❑ <br /> UDC 5/6 ❑ ❑ ❑ UDC fs21 1:1 ❑ ❑ <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 />