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SWRCB, January 2002 Page 1 of 7 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. I _ FArII.ITV INFORMATION Facility Name: Pilot/Flying J #618 Date of Testing: 7/27/2011 Facility Address: 1501 N. Jack Tone Road Ripon CA, Facility Contact: Manager Phone: 209-599-414 Date Local Agency Was Notified of Testing: 7/8/2011 Name of Local Agency Inspector (if present during testing): None I IL 0111110 1%0 01111111 19 W 2 TFCTTNf_' CONTRACTOR INFORMATION of Ir, a A 11199 Company Name: Jones Covey Group,Inc. Pass Technician Conducting Test: Edwin Coreas SAN JOAQUIN COUNTY Credentials: ❑ CSLB Licensed Contractor IRONMENTAr- ® SWRCB Licensed Tank Tester License Type: Not Tested License Number:03-1652 Manufacturer Manufacturer Training Component(s) Date Training Expires Incon TS -STS 7/12/2013 ❑ Tank #4 Unl. 87 vapor bucket ® ❑ ❑ ❑ 'A_ SiTMMARV OF TF,ST RF.SLTI,TS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Tank #1 Diesel STP sump ® ❑ ❑ Tank #4 Unl. 87 vapor bucket ® ❑ ❑ ❑ Tank #2 Diesel STP sump ® ❑ ❑ Tank #5 Plus 91 vapor bucket ® ❑ ❑ ❑ Tank #3 Diesel STP sump ® ❑ ❑ ❑ Tank #1 DSL secondary piping ❑ PUF ❑ ❑ Tank #4 Unleaded 87 STP sump E:❑ Tank #2 DSL secondary piping ❑ ❑ Tank #5 Premium 91 STP sump ❑ Tank #3 DSL secondary piping ❑ ❑ El Tank #6 Auto Diesel STP sump F-1❑ Siphon #1 secondary piping El❑ L1Tank #1 Diesel fill bucket IZN E] F-]E] Siphon #2 secondary piping ❑ ® ❑ Tank #2 Diesel fill bucket ❑ ❑ F -]Siphon #3 secondary piping F-1ElTank #3 Diesel fill bucket ❑ ❑ ❑ Siphon #4 secondary pipingTank #4 Unleaded 87 fill bucket ❑ ❑ Tank #3 87 secondary piping ® ❑ ❑ ❑ Tank #5 Plus 91 fill bucket ® ❑ ❑ I Tank #4 91 secondary piping ® 1 ❑ 1 ❑ ❑ Tank #6 Auto Diesel fill bucket ❑ ❑ Tank #5 ADSL secondarypiping ® I ❑ 1 ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Water - Recycle and Reuse 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:A� Date 7/27/2011 �7