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RECE <br /> 1VEjD <br /> SWRCB,January 2002 age o <br /> Secondary Containment Testing Report Form SEP 14 <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 for VHEALTH <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to tagency. <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 I 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 Jr/Issac Garcia <br /> Credentials: ®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 01-20-2016 <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 Sat. x ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Line Diesel Tank#6 >9 ❑ ❑ ❑ - ❑ ❑ ❑ <br /> Secondary 30 sat to 30 Main ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ g ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ K ❑ ❑ ❑ <br /> ❑ ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ® ❑ ❑ ❑ <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:8/19/14 <br />