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SWRCI9,January 2002 Page 3. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: FLYING J 0500075 Date of Testing: 08/04/2008 Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 Facility Contact: JOSE Phone: (2 0 9) 599-4141 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JARROD COOKE Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: a I License Number: 743160 Manufacturer Training Manufacturer Component(s) Date Training Expires tanknology all 07/17/2009 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made UDC 19 ❑ ❑ ON ❑ UDC 25 El ❑ ❑ El- UDC UDC 19sat FRI ❑ ❑ UDC 25sat El ❑ ❑ ❑ UDC 20 F7�:l ❑ ❑ ❑ UDC 26 ❑ ❑ ❑ UDC 20satEl ❑ ❑ UDC 26sat F-1 El El UDC 21a F] ❑ ❑ UDC 27 El EI F-1 El UDC 21sat x ❑ ❑ ❑ UDC 27sat FRI ❑ ❑ ❑ UDC 22 ❑X El 1:1 1:1unc 28 ❑ ❑ ❑ UDC 22sat x ❑ ❑ UDC 28sat x ❑ ❑ ❑ UDC 23 I F-1 ❑ ❑ UDC 29 El ❑ El El UDC 23sat x ❑ ❑ ❑ UDC 29sat o ❑ ❑ ❑ UDC 24 ❑ ❑ El 30 x ❑ ❑ ❑ UDC 24satEl ❑ ❑ ElUDC 30sat El ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: taken water dog CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 08/04/2008