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A V <br />SWRCB, January 2002 age of� <br />Secondary Containment Testing Report Form DEC 0 8 2016 <br />This form is intended for use by contr actors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of thisform to report results for all components tested. The completed form, WriteW PR&APAa-, L H,,ALT <br />printouts fi-om tests (if applicable), should be provided to the facility owner/operator for submittal to the Joca <br />1. FACILITY INFORMATION <br />Facility Name: Pilot Flying J - Frazier Park #618 Date of Testing: 11/01/2016 <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 />Compan Name: Jones Covey Croup, Inc. <br />Technician Conducting Test: Joseph Gonzalez <br />Credentials: ❑ CSLB Licensed Contractor <br />License Type: A, B and Haz <br />0 SWRCB Licensed Tank Tester <br />License Number: 804431 <br />Manilfgcturer Training <br />ivlanuracturer C:om onent s Date Training Expires <br />INCON- TS -STS 9037453707 04/30/2017 <br />ICC 8341128 03/14/2017 <br />3. SUMMARY OF TEST RESULTS <br />Component Pass Fail Not Repairs <br />A Tested Made Component <br />Not <br />Pass Faii Tested <br />Repairs <br />Made <br />87 Tank #4 secondary tg 0 0 0 <br />❑ <br />0 <br />0 <br />0 <br />91 Tank #5 secondary lli ❑ ❑ ❑ <br />❑ <br />0 <br />0 <br />0 <br />Diesel Tank #6 secondary 19 ❑ 0 0 <br />❑ <br />❑ <br />❑ <br />❑ <br />Siphon T#1 to T#2 secondary IN ❑ ❑ ❑ <br />❑ <br />0 <br />0 <br />0 <br />Siphon T#2 to T#3 secondary T ❑ ❑ ❑ <br />❑ <br />❑ <br />D <br />0 <br />T#2 and T#3 Trans to UDC's ❑ ® a ❑ <br />❑ <br />❑ <br />0 <br />0 <br />Trans sump to disp.#19&#20 11 M ❑ ❑ <br />❑ <br />0 <br />0 <br />0 <br />0 0 0 0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ 0 0 0 <br />❑ <br />D <br />0 <br />❑ <br />❑ 0 0 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ D 0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />D <br />❑ <br />❑ <br />Nhydrostatic testing was performed, describe what was done with the water after completion of tests: <br />***Unable to hydrostatic test the diesel UDCs 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 of my knowledge, the facts stated In this document are accurate and in full compliance with legal requirements <br />Technician's Signature: ` Date: 11/01/2016 <br />