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SWRCB, January 2002 Pagel 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. FACILITY INFORMATION Facility Name: Pilot/Flying J #618 Date of Testing: 7/27/2011 Facility Address: 1501 N. Jack Tone Road Ripon CA, Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): None TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group,Inc. Pass Technician Conducting Test: Edwin Coreas Not Credentials: ❑ CSLB Licensed Contractor ® SWRCB Licensed Tank Tester License Type: Fail License Number:03-1652 Manufacturer Manufacturer Training Component(s) Date Training Expires Incon TS -STS 7/12/2013 ❑ ❑ Sat Dispenser #20 ® ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Tested Not Repairs Made Component Pass Fail Not Tested Repairs Made Dispenser Containment #1-2 ® ❑ ❑ ❑ Sat Dispenser #20 ® ❑ ❑ ❑ Dispenser Containment #3-4 ❑ ❑ ❑ Main Dispenser #21 ® ❑ ❑ ❑ Dispenser Containment #5-6 ® ❑ ❑ ❑ Sat Dispenser #21 ® ❑ ❑ ❑ Dispenser Containment #7-8 ® ❑ ❑ Main Dispenser #22 ❑ ® ❑ ❑ Dispenser Containment #9-10 ® ❑ ❑ ❑ Sat Dispenser #22 ® ❑ ❑ ❑ Dispenser Containment #11-12 E❑ ❑ Main Dispenser #23 ® ❑ ❑ ❑ Dispenser Containment #13 ® ❑ ❑ F-1 atDispenser #23 ® ❑ ❑ ❑ Dispenser Containment #14-15 ® ❑ Main Dispenser #24 ® ❑ ❑ ❑ Dispenser Containment #16 ❑ ❑ ❑ Sat Dispenser #24 ❑ ® ❑ ❑ Main Dispenser #19 ❑ ❑ Main Dispenser #25 ® ❑ ❑ ❑ Sat Dispenser #19 Z❑ ❑ ❑ Sat Dispenser #25 ® ❑ ❑ ❑ Main Dispenser #20 ❑ ❑ I Main Dispenser #26 ❑ ❑ ❑ ❑ 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: Date 7/27/2011