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SWRCB,January 2002 Page 1. Secollary Containment Testing Aport 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: FLYING J 0500075 Date of Testing: 05/31/2007 Facility Address: 1501 N. JACK TONE RD RIPON, CA, 95366 Facility Contact: JOSE Phone: (2 0 9) 599-4141 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: DOUGLAS HARTY Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: 743160 1 License Number: Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made Spill Box 1 DIE FILL E ❑ ❑ ❑ ❑ ❑ ❑ EI- Spill Spill Box 2 DIE FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 3 DIE FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 4 UNL FILL a ❑ ❑ ❑ ❑ ❑ ❑ 01 Spill Box 5 PLU FILL IF-I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 6 SUP FILL FRI ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 7 OIL FILL ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 11:111:11 ❑ 1 ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: LEFT TEST WATER IN DRUM ON SITE 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: r Date: 05/31/2007