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SWRCB,January 2002 Page 1 of 21 <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 618 Ripon Date of Testing: 11-13-19 <br /> Facility Address: 1501 Jack Tone Rd. Ripon Ca, 95366 <br /> Facility Contact: Manager Phone: (209) 599-4141 <br /> Date Local Agency Was Notified of Testing: 11-6-2019 <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Jose Ochoa <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B and Haz License Number:804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> I NCON TS-STS 8-23-21 <br /> ICC 8004551-UT 10-28-2021 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass bail Not Repairs <br /> Tested Made Tested Made <br /> Tank-1 Annular ❑ ❑ ® ❑ UDC 1-2 ® ❑ ❑ ❑ <br /> Tank-2 Annular ❑ ❑ ® ❑ UDC 3-4 ® ❑ ❑ ❑ <br /> Tank-3 Annular ❑ ❑ ® ❑ UDC 5-6 ® ❑ ❑ ❑ <br /> Tank-4 Annular ❑ ❑ ® ❑ UDC 7-8 ® ❑ ❑ ❑ <br /> Tank-5 Annular ❑ ❑ ® ❑ UDC 9-10 ® ❑ ❑ ❑ <br /> Tank-6 Annular ❑ ❑ ® ❑ UDC 11-12 ® ❑ ❑ ❑ <br /> Tank-1 STP Sump A ❑ ❑ ❑ UDC 13 ❑ ® ❑ ❑ <br /> Tank-2 STP Sump ® ❑ ❑ ❑ UDC 14-15 ® ❑ ❑ ❑ <br /> Tank-3 STP Sump ® ❑ ❑ ❑ UDC 16 ® ❑ ❑ ❑ <br /> Tank-4 STP Sump A ❑ ❑ ❑ UDC 19 Main x ❑ ❑ ❑ <br /> Tank-5 STP Sump ® ❑ ❑ ❑ UDC 19 Satellite RU ❑ ❑ ❑ <br /> Tank-6 STP Sump ® ❑ -1 ❑ UDC 20 Main ® ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR COND11rVE i=n <br /> To the best of my knowledge,the facts stated in this document are accurate and in fu ian i u <br /> Technician's Signature:_ (/ _ Date: 11-13-19 NOV u 7 2019 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />