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0 <br />SWRCB, January 2002 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 (f 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 #617 Date of Testing: 11/19/2013 <br />Facility Address: 15100 Thornton Rd, Lodi, Ca, 95242 <br />Facility Contact: Manager Phone: <br />Date Local Agency Was Notified of Testing: 11/14/2013 <br />Name of Local Agency Inspector (if present during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Jones Covey Group, Inc. <br />Technician Conducting Test: Arturo Perez Jr, Issac Garcia <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B and Haz I License Number: 804431 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC 8061052 01-26-2015 <br />Incon TS -STS 01-18-2014 <br />Component <br />3. SUMMA.-. <br />1 <br />o <br />o0 <br />0000 <br />®000 <br />0000 <br />®000 <br />®000 <br />©000 <br />0000; <br />0000' <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000,: <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water was recycled in water trailer for reuse. <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: "' �l Date: 11/19/2013 <br />