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SWRCB,January 2002 Page 6 of 20 <br /> Secondary Containment Testing Report Farm <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 for►n, written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot Flying J 617 Lodi Date of Testing: 07/17/2025 <br /> Facility Address: 15237 N. Thornton Road <br /> Facility Contact: Manager Phone: (530)724-3060 <br /> Date Local Agency Was Notified of Testing: Unknown <br /> Name of Local Agency Inspector(fpresent during testing): Inspector not present. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group, Inc. <br /> Technician Conducting Test: Justin Zorn <br /> Credentials: li?CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A, B HAZ License Number: 804431 <br /> EM <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Incon Level 4ITS-STS O4/04/2027 <br /> ICC Service Technician 19157862 02/11/2027 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Product Line 91 Product Line [,�' ❑ ❑ ❑ <br /> ADSL Product Line 87 Siphon Line [�' ❑ ❑ ❑ <br /> UDC 112 5? ❑ ❑ ❑ UDC 314 li? I ❑ ❑ I ❑ <br /> UDC 516 11? ❑ ❑ ❑ UDC 718 11? ❑ ❑ ❑ <br /> UDC 9110 IV ❑ ❑ ❑ UDC 11112 IV ❑ ❑ ❑ <br /> UDC 13 [r? ❑ ❑ ❑ UDC 14115 [r? ❑ ❑ ❑ <br /> UDC 16117 11? ❑ ❑ ❑ UDC 18 11? ❑ ❑ ❑ <br /> T1 Fill T2 Fill [��' ❑ ❑ ❑ <br /> T3 Fill T4 Fill [,�' ❑ ❑ ❑ <br /> T5 Fill [ ❑ ❑ ❑ T1 STP 11? ❑ ❑ ❑ <br /> T2 STP ❑ ❑ ❑ T3 STP 0' ❑ ❑ ❑ <br /> T4 STP ❑ ❑ ❑ T5 STP [if ❑ ❑ ❑ <br /> If hydrostatic testing was perfonned,describe what was done with the water after completion of tests: <br /> Oil Water Seperator <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:07/1712025 <br />