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0 0 RECEIVED <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form SEP 1 <br /> This form is intended for use by contractors performing periodic testing of UST secondary contai L <br /> EALTH <br /> appropriate pages of this form to report results for all components tested. The completed form, written tes g <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the Z racy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#618 Date of Testing: 8/19/2014 <br /> Facility Address: 1501 North Jack Tone Road, Ripon, Ca, 95366 <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing: 8/13/14 <br /> Name of Local Agency Inspector(if present during testing): Elena K. Manzo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Arturo Perez, Issac Garcia <br /> Credentials: 9 CSLB Licensed Contractor El 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 /> ICC 8061052 01-26-2015 <br /> Incon TS-STS 01-20-2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 28 Sat. ❑ ❑ ❑ Secondary Line 91 Tank#5 g ❑ ❑ ❑ <br /> UDC 29 Main x ❑ ❑ ❑ Secondary 19 sat to 19 Main x ❑ ❑ ❑ <br /> UDC 29 Sat. iK ❑ ❑ ❑ Secondary 20 sat to 20 Main X ❑ ❑ ❑ <br /> UDC 30 Main g L] 11 [1Secondary 21 sat to 21 Main L ❑ El ❑ <br /> UDC 30 Sat. - ❑ ❑ ❑ Secondary 22 sat to 22 Main x ❑ ❑ ❑ <br /> Diesel STP Tank#1 x ❑ ❑ ❑ Secondary 23 sat to 23 Main g ❑ ❑ ❑ <br /> Diesel STP Tank#2 x ❑ ❑ ❑ Secondary 24 sat to 24 Main x ❑ ❑ ❑ <br /> Diesel STP Tank#3 9 ❑ ❑ ❑ Secondary 25 sat to 25 Main K ❑ ❑ ❑ <br /> Secondary Line Diesel Tank#1 _9 ❑ ❑ ❑ Secondary 26 sat to 26 Main ® ❑ ❑ ❑ <br /> Secondary Line Diesel Tank#2 x ❑ ❑ ❑ Secondary 27 sat to 27 Main K ❑ ❑ ❑ <br /> Secondary Line Diesel Tank#3 19 ❑ ❑ ❑ Secondary 28 sat to 28 Main K ❑ ❑ ❑ <br /> Secondary Line 87 Tank#4 ❑ ❑ ❑ Secondary 29 sat to 29 Main ® ❑ ❑ ❑ <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 with legal requirements <br /> Technician's Signature: Date:8/19/2014 <br />