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L <br /> 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 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: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B and Haz License Number:804431 <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> I ncon 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 /> UDC 20&20s ❑ ® ❑ ❑ Diesel Tank#2 Secondary ❑ ® 0 0 <br /> UDC 21 &21s ❑ ® ❑ ❑ Diesel Tank#3 secondary ❑ ® 0 0 <br /> UDC 22 &22s ❑ ® ❑ ❑ 87 Tank#4 secondary ❑ ® ❑ 1 0 <br /> UDC 23&23s ❑ ® 0 0 91 Tank#5 Secondary ❑ ® ❑ 0 <br /> UDC 24&24s ❑ ® ❑ ❑ Diesel Tank#6 Secondary ❑ ® ❑ ❑ <br /> UDC 25&25S ❑ ® 0 ❑ Siphon T#1 to T#2 secondary ® ❑ ❑ ❑ <br /> UDC 26&26s ❑ ® ❑ ❑ Siphon T#2 to T#3 Secondary X ❑ ❑ ❑ <br /> UDC 27&27s ❑ ® ❑ ❑ Vent secondary T#2 to T#3 ® ❑ ❑ 0 <br /> UDC 28&28s ❑ ® ❑ ❑ Vent secondary T#1 to T#2 ❑ ® 0 0 <br /> UDC 29&29s ❑ ® 0 0 0 0 0 ❑ <br /> UDC 30&30s ❑ ® ❑ ❑ 0 0 0 0 <br /> Diesel Tank#1 Secondary ❑ 1 ® 0 ❑ 0 0 0 0 <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 compliance wi s <br /> ED <br /> Technician's Signature: Date:11/06/2013 <br /> 2313 <br /> ENVIRONMENTAL <br />