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SWRCB, January 2002 <br />B '4� A.. V i�. <br />Secondary Containment Testing Report For <br />This farm is Intended for use by contractors performing periodic testing of UST secondary containment systems. IDEAeO 8 201 <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION V]70' 'V' --N j°-° ' '` <br />Facility Name: Pilot Flying J - Frazier Park #618 Date of Testin : 11/01/2 t- :-<''' <br />Facility Address: 1501 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 {if present during testing): N/A <br />2. TESTING CONTRACTOR INFORMATION <br />Cogjpan Name: Jones Covey Group, Inc. <br />Technician Conducting Test: Joseph Gonzalez <br />Credentials: ❑ CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A, a and Haz License Number: 804431 <br />Manufacturer Tralninne <br />Manufacturer Component(s) Date Training Expires <br />INCOW TS -STS 9037453707 04/30/2017 <br />ICC 8341128 03/14/2017 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />p <br />Pass Fail Not <br />Tested <br />Repairs <br />Made <br />Component <br />Not <br />Pass Fall Tested <br />Repairs <br />Made <br />UDC 20 satellite <br />❑ <br />® <br />❑ <br />❑ <br />UDC 26 satellite <br />❑ <br />® <br />❑ <br />❑ <br />UDC 21 main <br />0 <br />IN <br />0 <br />❑ <br />UDC 27 main <br />❑ <br />® <br />❑ <br />D <br />UDC 21 satellite <br />0 <br />® <br />D <br />❑ <br />UDC 27 satellite <br />0 <br />® <br />❑ <br />❑ <br />UDC 22 main <br />❑ <br />® <br />❑ <br />❑ <br />UDC 28 main <br />❑ <br />❑ <br />❑ <br />UDC 22 satellite <br />11 <br />® <br />❑ <br />❑ <br />UDC 28 satellite <br />❑ <br />® <br />❑ <br />❑ <br />UDC 23 main <br />❑ <br />® <br />❑ <br />❑ <br />UDC 29 main <br />❑ <br />❑ <br />❑ <br />UDC 23 satellite <br />0 <br />® <br />❑ <br />❑ <br />UDC 29 satellite <br />❑ <br />® <br />❑ <br />❑ <br />UDC 24 main <br />❑ <br />❑ <br />❑ <br />UDC 30 main <br />❑ <br />® <br />❑ <br />❑ <br />UDC 24 satellite <br />❑ <br />1@ <br />❑ <br />❑ <br />UDC 30 satellite <br />❑ <br />® <br />❑ <br />UDC 25 main <br />❑ <br />® <br />❑ <br />❑ <br />Diesel T#1 Diesel RV secondary <br />® <br />❑ <br />❑ <br />UDC 25 satellite <br />11 <br />® <br />❑ <br />❑ <br />Diesel T#2 to Trans secondary <br />® <br />❑ <br />❑ <br />dD <br />UDC 26 main <br />❑ <br />0 <br />D <br />Diesel T#3 to Trans secondary <br />Ia <br />❑ <br />❑ <br />If hydrostatic testing was perfomied, describe what was done with the water after completion of tests: <br />***Unable to hydrostatic test the diesel UDC's due to missing boots*** <br />***Satellites will be tested at the time of dispenser main with the use of jumpers*** <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best ofmy knowledge, the facts stated In tkls document are accurate and in fall compliance with legal requirements <br />Technician's Signature: �� Date: 11/01/2016 <br />