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SWRCB, January 2002 Page of 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Pilot -Flying J #617 Date of Testing: 11/19/2013 Facility Address: 15100 Thornton Rd, Lodi, Ca, 95242 Facility Contact: Manager Phone: Date Local Agency Was Notified of Testing: 10/22/2013 Name of Local Agency Inspector (f present during testing): NA 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group, Inc. Technician Conducting Test: Arturo Perez Jr, Issac Garcia Credentials: F9 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B and Haz License Number: 804431 Manufacturer Training Manufacturer Component(s)) Date Training Expires I ncon TS -STS 01-18-2014 1 CC 8061052 01-26-2015 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made T#1 87 Annular ❑ ❑ ® ❑ Tank#3 87 Fill Sump ® ❑ ❑ ❑ T#2 87 Annular ❑ ❑ ® ❑ Tank#4 87 Fill Sump ❑ ❑ ❑ T#3 87 Annular ❑ ❑ ® I ❑ Tank#5 91 Fill Sump ❑ I ❑ ❑ T#4 87 Annular ❑ ❑ 91 ❑ UDC 9-10 ❑ ❑ ❑ T#5 91 Annular ❑ ® ❑ Secondary From T#1 to T#2 9 ❑ ❑ ❑ Tank#1 87 STP EK ❑ ❑ ❑ Secondary From T#2 to T#3 ❑ ® ❑ ❑ Tank#2 87 STP ❑ ® ❑ ❑ Secondary From T#3 to T#4 9 ❑ ❑ ❑ Tank#3 87 STP ❑ ® ❑ ❑ 87 Secondary ❑ ® ❑ ❑ Tank#4 87 STP ® ❑ ❑ ❑ 91 Secondary ❑ ® ❑ ❑ Tank#5 91 STP ❑ ® ❑ ❑ UDC 1-2 ❑ ® ❑ ❑ Tank#1 87 Fill Sump ® ❑ ❑ ❑ UDC 3-4 ❑ ® ❑ ❑ Tank#2 87 Fill Sump ❑ ❑ ❑ I UDC 5-6 ❑ ® ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water was recycled in water trailer for reuse. 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: 11/19/2013