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SWRCB, January 2002 111-1141 k so Page of 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. i•ry NXTU DAA A'rInN Facility Name: Flying J Travel Center Date of Testing: 6/6/2013 Facility Address: 1501 N Jack Tone Rd. Ripon, California 95326 Facility Contact: Manager Brian Phone: 209-599-4141 Date Local Agency Was Notified of Testing: 5/30/2013 Name of Local Agency Inspector (f present during testing): N/A 17 -1rVQrr1NC rnNrrUACTnR INFORMATION s cTTr41%4ADV n1W TIVQT i2F.CTT1.TC Component Pass Fail T seed RM des Component Pass Fail Not Tested Repairs N ade T-1 Secondary Pipe X ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-5 91 STP Sump Hydrostatic x ❑ ❑ ❑ ❑ ❑ ❑ ❑ RV UDC 16 Hydrostatic x ❑ ❑ ❑ ❑ El 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F-1 ❑ ❑ El El❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ El El❑ ❑ ❑ El Et] ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water transferred into 55gallon drums, properly labeled and staged for recovery. 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: Al Date: 6/6/2013