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f <br /> SWRCB,January 2002 Page of <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 teRWBV-Ef,,: <br /> ocedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#618 Date of Testing: 2/17/201 <br /> Facility Address: 1501 N. Jacktone Rd Ripon CA 95366 <br /> Facility Contact: Manager Phone: 209-599-4141ENVIRMIREN <br /> Date Local Agency Was Notified of Testing: 2/9/2015 <br /> Name of Local Agency Inspector('(present during testing): Elena Manzo <br /> 2. TESTING CONTRACTORINFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Issac Garcia <br /> Credentials: 9 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 /> Franklin Fueling 7177093705 INCON Level 4 4/16/2015 <br /> ICC 8192172 UST Service Tech 1/24/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Dispenser 25 UDC N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El El El ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test water stored in labeled hazardous waste drum and left on site for proper removal. <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: a-- Date:2/17/2015 <br />