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�A <br />SWRCB, January 2002 <br />M ApRge 4_M�_L4_ <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary contain Y)RQN Uk MIA L H EA LT H <br />appropriate pages of this form to report results for all components tested. The completed form, written test BERART49NT <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />Facility Name: Flying J #618 1 Date of Testing: 12.14.16 - 12.16.16 <br />Facility Address: 1501 N. Jack Tone Rd. Ripon, CA. 95366 <br />Facility Contact: Manager Phone: (209)599-4141 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ii(present during testing): <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fall <br />Not <br />Tested <br />Repairs <br />Made <br />T5- 91 STP Sump <br />El <br />X1 <br />0 <br />91 <br />Ll <br />❑ <br />11 <br />[ I <br />T6- Diesel STP Sump <br />❑ <br />11 <br />W] <br />Ll <br />❑ <br />0 <br />[ I <br />T1- Trans Sump to Disp. 19M/20M <br />Li <br />0 <br />1 11 <br />0 <br />, 11 <br />0 <br />L I <br />Disp. 19 Master to 19 Satellite <br />Li <br />Li <br />Li <br />El <br />❑ <br />11 <br />[ I <br />Disp. 20 Master to 20 Satellite <br />W <br />❑ <br />El <br />11 <br />El <br />❑ <br />11 <br />[ I <br />Disp. 19 Master UDC <br />X <br />El <br />El <br />0 <br />E <br />❑ <br />Ll <br />E I <br />Disp. 19 Satellite UDC <br />A <br />El <br />El <br />El <br />L <br />❑ <br />11 <br />E I <br />Disp. 20 Master UDC <br />A <br />El <br />El <br />D <br />Ll <br />11 <br />11 <br />E I <br />Disp. 20 Satellite UDC <br />ix <br />❑ <br />11 <br />11 <br />11 <br />0 <br />0 <br />[ I <br />E <br />❑ <br />El <br />11 <br />11 <br />11 <br />11 <br />11 <br />11 <br />Li <br />11 <br />11 <br />11 <br />11 <br />L1 <br />Li <br />Li <br />Li <br />D <br />I El <br />El <br />11 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />T5- 91 STP Sump Failed, needs more repairs done & re -tested. <br />Pumped to marked barrels & recycled any remaining test water. <br />All boots removed from secondary & left in the normal operating position. <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: 12.14.16 - 12.16.16 <br />U <br />