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REOFIVED <br /> SWRCB,January 2002 NOV 3 0 2016 Page 1 of 12 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST s rpt st e <br /> appropriate pages of this form to report results for all components tested. The completed �y � cedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for su t a o e oca regulatory agency. <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(f present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Joseph Gonzalez <br /> Credentials: ®CSLB Licensed Contractor X 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 /> INCOW TS-STS 9037453707 04/30/2017 <br /> ICC 8341128 03/14/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank#1 Diesel Annular ❑ ❑ ® ❑ UDC 1-2 ® ❑ ❑ ❑ <br /> Tank#2 Diesel Annular ❑ ❑ ® ❑ UDC 3-4 ❑ ❑ ❑ <br /> Tank#3 Diesel Annular ❑ ❑ ® ❑ UDC 5-6 ® ❑ ❑ ❑ <br /> Tank#4 87 Annular ❑ ❑ ® ❑ UDC 7-8 ® ❑ ❑ 1 ❑ <br /> Tank#5 91 Annular ❑ ❑ ® ❑ UDC 9-10 ❑ ❑ ❑ <br /> Tank#6 Diesel Annular ❑1 ❑ ® ❑ UDC 11-12 C ❑ ❑ ❑ <br /> Tank#1 Diesel STP ❑ ❑ ❑ UDC 13 ❑ ❑ ❑ <br /> Tank#2 Diesel STP ❑ ❑ ❑ UDC 14-15 ® ❑ ❑ ❑ <br /> Tank#3 Diesel STP ❑ ❑ I ❑ UDC 16 ® ❑ ❑ ❑ <br /> Tank#4 87 STP x ❑ ❑ ❑ UDC 19 main ❑ ® ❑ ❑ <br /> Tank#5 91 STP _, ® ❑ ❑ UDC 19 satellite ❑ ® ❑ ❑ <br /> Tank#6 Diesel STP j EI 1 ® ❑ ❑ UDC 20 main ❑ ® ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> "Water was recycled in water trailer for future re-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 /> Technician's Signature: �� Date:11/01/2016 <br />