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SWRCB,January 2002 Pag 11-M <br /> Secondary Containment Testing Report Formi„� � <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 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 <br /> Facility Name: Pilot Flying J 618 1 Date of Testing: 07/27/2016 <br /> Facility Address: 1501 N. Jacktone Rd, Ripon CA 95366 <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing: 7/18/2016 <br /> Name of Local Agency Inspector(f present during testing): Elena Manzo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Issac Garcia <br /> Credentials: X CSLB Licensed Contractor -1 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 7177093705 Level 4 04/19/2017 <br /> ICC 8192172 Service Tech 01/24/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 11-12 x ❑ ❑ ❑ 7 ❑ ❑ ❑ <br /> UDC 13 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 14-15 X ❑ ❑ __1 ❑ ❑ ❑ <br /> UDC 16 ❑ ❑ ❑ 7 ❑ ❑ ❑ <br /> Auto Diesel Secondary ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Secondary ❑ ❑ ❑ ❑ :1 ❑ <br /> 91 Secondary ❑ ❑ ❑ ❑ ❑ ❑ <br /> RV Secondary ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T71 D <br /> ]d <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test water recycled into water trailer for future use. <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 /> Technicians Signature: Date:07/27/2016 <br />