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•SWRCB,January 20020 40 Page 3. <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 /> FacilityName: FLYING "J" 0500079 DateofTesting: 07/09/2008 <br /> Facility Address: 15237 THORNTON RD LOD I, CA, 95242 <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 SWRCB Licensed Tank Tester <br /> License Type: a 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 /> unc 25 0 El ❑ ❑ ❑ ❑ ❑ <br /> UDC 25sat � ❑ ❑ 1:1 <br /> UDC 26 FRI ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> UDC <br /> UDC 26sat E ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 27 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 27sat El ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 28 FRI ❑ ❑ ❑ ❑ ❑ F-1 El- <br /> UDC <br /> UDC 28sat El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 29 E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 29sat � ❑ ❑ ❑ ❑ ❑ ❑ El <br /> UDC 30 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 30sat E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 />