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SWRCB,January 2002 Page of <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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#618 1 Date of Testing: 11/06/2013 <br /> Facility Address: 1501 Jacktone Rd. Ripon, Ca 95366 <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing: 10/22/13 <br /> Name of Local Agency Inspector(if present during testing): Elaina Manzo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Arturo Perez Jr, Issac Garcia <br /> Credentials: 9 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B and Haz License Number:804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS-STS 01-18-2014 <br /> ICC 8061052 01-26-2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank#1 Diesel Annular ❑ ❑ ® ❑ UDC 1-2 ❑ ® ❑ ❑ <br /> Tank#2 Diesel Annular ❑ ❑ ® ❑ UDC 3-4 ❑ ® ❑ ❑ <br /> Tank#3 Diesel Annular ❑ ❑ ® ❑ UDC 5-6 ❑ ® ❑ ❑ <br /> Tank#4 87 Annular ❑ ❑ ® ❑ UDC 7-8 ❑ ® ❑ ❑ <br /> Tank#5 91 Annular ❑ ❑ ® ❑ UDC 9-10 ❑ ® ❑ ❑ <br /> Tank#6 Diesel Annular ❑ ❑ ® ❑ UDC 11-12 ❑ ® ❑ ❑ <br /> Tank#1 Diesel STP ❑ ® ❑ ❑ UDC 13 9 ❑ ❑ ❑ <br /> Tank#2 Diesel STP ❑ ® ❑ ❑ UDC 14-15 ® ❑ ❑ ❑ <br /> Tank#3 Diesel STP ❑ ® ❑ ❑ UDC 16 ® ❑ ❑ ❑ <br /> Tank#4 87 STP C» ❑ ❑ ❑ UDC 17& 17s ❑ ® ❑ ❑ <br /> Tank#5 91 STP ® ❑ ❑ ❑ UDC 18& 18s ❑ ® ❑ ❑ <br /> Tank#6 Diesel STP ® ❑ . ❑ ❑ UDC 19& 19s ❑ ® ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> *Water was recycled in water trailer for reuse. <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 complianc e <br /> L D <br /> Technician's Signature: f "J Date:11/06/2013 <br /> ENVIRONMENTAL <br /> S fir u a DNk'.1, TMENT <br />