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SWRCB,January 2002 Page 3 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: 209-599-414 <br /> Date Local Agency Was Notified of Testing: %,-i L.. D <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. -r <br /> Technician Conducting Test: Joseph Gonzalez <br /> Credentials: DEPARTMENT <br /> ❑CSLB Licensed Contractor El 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 /> 87 Tank#4 secondary ® El 11 ® ❑ ❑ <br /> 91 Tank#5 secondary ❑ ® ❑ ❑ ® ❑ ❑ <br /> Diesel Tank#6 secondary ❑ ® ❑ ❑ L 91 1 ❑ ❑ <br /> Siphon T#1 to T#2 secondary L ® ❑ ❑ ® ❑ ❑ <br /> Siphon T#2 to T#3 secondary ❑ ® ❑ ❑ ❑ ® ❑ ❑ <br /> T#2 and T#3 Trans to UDC's LI ® ❑ ❑ ❑ ® ❑ ❑ <br /> Trans sump to disp.#19&#20 ❑ ® ❑ ❑ ® ❑ ❑ <br /> a ❑ ❑ ❑ ® ❑ ❑ <br /> ® ❑ ❑ ❑ ® ❑ ❑ <br /> a ❑ E_j ® ❑ ❑ ❑ <br /> ® ❑ ❑ ® ❑ ❑ ❑ <br /> L ® ❑ ❑ ® ❑ ❑ ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:11/01/2016 <br />