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SWRCB,January 2002 Page 2 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(f 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(f 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 Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 20 Satellite UI ❑ ❑ UDC 26 Satellite ® ❑ ❑ ❑ <br /> UDC 21 Main x, ❑ ❑ ❑ UDC 27 Main ® ❑ ❑ ❑ <br /> UDC 21 Satellite IN ❑ ❑ ❑ UDC 27 Satellite ® ❑ ❑ ❑ <br /> UDC 22 Main ® ❑ ❑ ❑ UDC 28 Main ® ❑ ❑ ❑ <br /> UDC 22 Satellite ® ❑ ❑ ❑ UDC 28 Satellite ® ❑ ❑ ❑ <br /> UDC 23 Main ® ❑ ❑ ❑ UDC 29 Main ® ❑ ❑ ❑ <br /> UDC 23 Satellite A ❑ ❑ ❑ P <br /> 29 Satellite ® ❑ ❑ ❑ <br /> UDC 24 Main ® ❑ ❑ ❑ 30 Main ® ❑ ❑ ❑ <br /> UDC 24 Satellite ❑ x ❑ ❑ 30 Satellite ® ❑ ❑ ❑ <br /> UDC 25 Main x ❑ ❑ ❑ -1 STP Sec Product- RN ❑ ® ❑ ❑ <br /> UDC 25 Satellite x ❑ ❑ ❑ -2 Secondary Product ® ❑ ❑ ❑UDC 26 Main ❑ ❑ ❑ -3 Secondary Product Irl ❑ ❑ <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 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:_/1�p _ Date: 11-13-19 <br />