Laserfiche WebLink
IVI t L <br /> SWRCB,January 2002 MAR 2019,f <br /> Secondary Containment Testing Report Form.NVIRONMENTA! <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(ifapplicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#618 1 Date of Testing: 2/17/2015 <br /> Facility Address: 1501 N. Jack Tone Rd. Ripon, CA 95366 <br /> Facility Contact: Manager Phone: 209-599-4141 <br /> Date Local Agency Was Notified of Testing: 1/27/2015 <br /> Name of Local Agency Inspector(if present during testing): Elena Manzo <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Issac Garcia <br /> Credentials: 8 CSLB Licensed Contractor SVY'RCB Licensed Tank Tester <br /> License Type: A,B and Haz License Number:804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date TraininE Expires <br /> Franklin Fueling 7177093705 INCON Level 4 4/16/2015 <br /> ICC 8192172 Service Tech 2/24/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T1 STP x <br /> T2 STP x <br /> T3 STP x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test water stored in 55 Gallon labeled drums and left on site for proper removal. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> 'e7z' <br /> Technician's Signature: Date:2/17/2015 <br />