COMPLIANCE INFO_2019 - Laserfiche WebLink

Home Browse Search

SWRCB,January 2002 Page 3 of 21 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 618 Ripon Date of Testing: 11-13-19 Facility Address: 1501 Jack Tone Rd. Ripon Ca, 95366 Facility Contact: Manager Phone: (209)599-4141 Date Local Agency Was Notified of Testing: 11-6-2019 Name of Local Agency Inspector(if present during testing): N/A 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group,Inc. Technician Conducting Test: Jose Ochoa Credentials: A CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A,B and Haz License Number: 804431 Manufacturer Training Manufacturer Component(s) Date Training Expires INCON TS-STS 8-23-21 ICC 8004551-UT 10-28-2021 L__ 1� 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Tank-4 Secondary Product ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank-5 Secondary Product A ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank-6 Secondary Product A ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-1,T-2,T-3 Siphon Sec. Product A ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Returned to holding tank. 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: 11-13-19