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SWRCB,January 2002 Page 2 of 12 <br /> Secondary Containment Testing Report Form <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(f 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-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/A01 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Joseph Gonzalez ENVIRONMENTAL TH <br /> Credentials: ❑CSLB Licensed Contractor E 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-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 /> UDC 20 satellite ❑ ® ❑ ❑ UDC 26 satellite ® ❑ ❑ <br /> UDC 21 main ❑ ® ❑ ❑ UDC 27 main $1 ❑ ❑ <br /> UDC 21 satellite J ® ❑ ❑ UDC 27 satellite ® ❑ ❑ <br /> UDC 22 main ❑ ® ❑ ❑ UDC 28 main ❑ ® ❑ ❑ <br /> UDC 22 satellite ❑ ® ❑ ❑ UDC 28 satellite ® ❑ ❑ <br /> UDC 23 main ❑ ® ❑ ❑ UDC 29 main ® ❑ ❑ <br /> UDC 23 satellite ❑ ® ❑ ❑ UDC 29 satellite ® ❑ ❑ <br /> UDC 24 main ❑ ® ❑ ❑ UDC 30 main ❑ ® ❑ ❑ <br /> UDC 24 satellite o ® ❑ ❑ UDC 30 satellite ❑ ® ❑ ❑ <br /> UDC 25 main ❑ ® ❑ ❑ Diesel T#1 Diesel RV secondary ® ❑ ❑ ❑ <br /> UDC 25 satellite ❑ ® ❑ ❑ Diesel T#2 to Trans secondary ® ❑ ❑ ❑ <br /> UDC 26 main El ® ❑ ❑ Diesel T#3 to Trans secondary ® ❑ ❑ ❑ <br /> If hydrostatic testing was performed,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 of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: T Date:11/01/2016 <br />