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-SWRCB,January 2002 Page 2. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary>containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: FLYING "J" 0500079 DateofTesting: 07/09/2008 Facility Address: 15237 THORNTON RD LODI, CA, 95242 Facility Contact: DONNA TOMPKINS Phone: (2 0 9) 339-406G Date Local Agency Was Notified of Testing Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JARROD COOKE Credentials: El CSLB Licensed Contractor El SWRCB Licensed Tank Tester License Type: a I License Number: 743160 Manufacturer Training Manufacturer Component(s) Date Training Expires tanknology all 07/17/2009 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair ss Component Pass Fail Tested Made Component Pass Fail Tested Made Piping Sump 1 DIE � ❑ ❑ ❑ UDC 19 ❑ ❑ El- Piping Piping Sump 1 DIE ❑ ❑ ❑ UDC 19sat Fx] ❑ ❑ ❑ UDC 1/2 N ❑ ❑ ❑ UDC 20 FRI ❑ ❑ ❑ UDC 3/4 � F-1 F-1 o UDC 20sat � ❑ ❑ ❑ UDC 5/6 El ❑ ❑ ❑ UDC 21 El ❑ ❑ UDC 7/8 x ❑ ❑ ❑ UDC 21sat Fx] ❑ ❑ ❑ UDC 9/10 FRI ❑ ❑ El UDC 22 ❑ ❑ ❑ UDC 11/12 ❑ ❑ ❑ UDC 22sat ❑ ❑ ❑ UDC 13 X F-1 ❑ ❑ UDC 23 Fx] ❑ ❑ ❑ UDC 14/15X El ❑ ❑ UDC 23sat ❑ ❑ ❑ UDC 16/17 ❑ Fx1 ❑ F1 UDC 24 El a ❑ El- UDC UDC 18 El ❑ ❑ ❑ UDC 24sat E ❑ El ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: taken water dog CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 07/09/2008