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IS-INRCR,January 2002 Page 1. <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(if applicable},should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: FLYING "J" 0500079 DateofTesting: 07/09/2008 <br /> Facility Address: 15237 THORNTON RD LOD I, CA, 9 5 2 4 2 <br /> Facility Contact: DONNA TOMPKINS Phone: (2 0 9) 339-4066 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor El SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 1 DIE F-1 ❑ Secondary Pipe 1 DIE ❑ o ❑ ❑ <br /> Secondary Pipe 1 DIE o ❑ ❑ ❑ Secondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 2 DIE ElF-1ElSecondary Pipe 1 DIE ❑ ❑ El <br /> Secondary Pipe 2 DIE ❑ ❑ ❑ Secondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 3 DIE ❑ 1XI ❑ ❑ Secondary Pipe 1 DIE ❑ ❑ <br /> Secondary Pipe 3 DIEF-1 F—1El ElSecondary Pipe 1 DIE ❑ ❑ ❑ <br /> Secondary Pipe 4 UNL REGElEl <br /> 1:1 ❑ Secondary Pipe 5 PRE ❑ ❑ ❑ <br /> Secondary Pipe S PRE SUP ❑ ❑ ❑ Piping Sump 5 PRE F--1 ❑ ❑ ELI <br /> Secondary Pipe 1 DIE TSONEN ❑ ❑ ❑ Piping Sump 4 UNL ❑ F-1 ❑ <br /> Secondary Pipe 1 DIE TSONEE ❑ ❑ ❑ Piping Sump 3 DIE Ll- ❑ ❑ ❑ <br /> Secondary Pipe 1 DIE TSONEW ❑ m�j ❑ ❑ Piping Sump 2 DIE � ❑ ❑ ❑ <br /> Secondary Pipe 1 DIE El � El 1:1 Piping Sump 1 DIE ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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: 07/09/2008 <br />