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Ll SWRCB, January 2002 Page 2 of 14 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Flying J #618 1 Date of Testing: 1.11.17 Facility Address: 1501 N. Jack Tone Rd. Ripon, CA. 95366 Facility Contact: Manager Phone: (209)599-41 Not Tested Date Local Agency Was Notified of Testing Component Name of Local Agency Inspector (ifpresent during testing): Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made T2- Trans Sump to 21 M thru 25M X ❑ ❑ ❑ Disp. 24 Master UDC x ❑ ❑ C I Disp. 21 Master to 21 Satellite x ❑ ❑ ❑ Disp. 24 Satellite UDC ® ❑ ❑ C I Disp. 22 Master to 22 Satellite A ❑ ❑ ❑ Disp. 25 Master UDC ❑ ❑ C I Disp. 23 Master to 23 Satellite X ❑ ❑ ❑ ❑ ❑ ❑ C I Disp. 24 Master to 24 Satellite ® ❑ ❑ ❑ ❑ ❑ ❑ C I Disp. 25 Master to 25 Satellite ® ❑ ❑ ❑ ❑ ❑ ❑ C I Disp. 21 Master UDC ® ❑ ❑ ❑ ❑ ❑ ❑ C I Disp. 21 Satellite UDC x ❑ ❑ ❑ ❑ ❑ ❑ C I Disp. 22 Master UDC IN ❑ ❑ ❑ ❑ ❑ ❑ C 1 Disp. 22 Satellite UDC ❑ IJ ❑ ❑ ❑ ❑ ❑ ❑ Disp. 23 Master UDC ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disp. 23 Satellite UDC ® ❑ ❑ ❑ ❑ FEI T❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Disp. 22 Satellite Failed, needs repairs & re -tested. Pumped to marked barrels & recycled any remaining test water. All boots removed from secondary & left in the normal operating position. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: xr y Date: 1.11.17 a