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SWRCB,January 2002 go 0 Page of <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: PILOT-FLYING J#617 Date of Testing: 10/28/2011 <br /> Facility Address: 15000 N. THORNTON RD. LODI,CA. 95242 <br /> Facility Contact: Jose I Phone: 209-339-4066 <br /> Date Local Agency Was Notified of Testing:10/5/2011 <br /> Name of Local Agency Inspector(if present during testing): Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JONES COVEY GROUP INC. <br /> Technician Conducting Test: FRANK VASQUEZ <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A,B HAZ License Number: 804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON TS-STS 2/11/2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T-2 87 PRODUCT SECONDARY x <br /> T-4 87 PRODUCT SECONDARY X <br /> T-5 91 PRODUCT SECONDARY X <br /> T-1 to T-4 SYPHON SECONDARY X <br /> T-2 to T-4 MANIFOLD SECONDARY X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> T-2, T-4 PRODUCT SECONDARY NO VISUAL FAIL. <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 /> g <br /> Technician's Signature: <br /> Date:10/28/2011 <br /> 1 <br />