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a <br /> SWRCB,January 2002 LPage 1 of 3 <br /> Secondary Containment Testing Reportio mtiA <br /> This form is intendedfor use by contractors performing periodic testing of USTsecondary containmentsy4,t8,,#'�. ',,Us,�lihe <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures,and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Flying J#618 1 Date of Testing: 4.28.17 <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: 04/19/2017 <br /> Name of Local Agency Inspector(fpresent during testing): Vicki McCartney <br /> 2. TESTING CONTRACTOR INFORMATION <br /> =Conducting <br /> Jones Covey Group,Inc. <br /> ting Test: James Blaine <br /> CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> and Haz License Number:804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON 1006583708 9.28.2018 <br /> ICC 8469775 7.15.2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T5-91 STP Sump 91 ❑ ❑ ❑ C I <br /> Disp. 22 Satellite UDC ® ❑ ❑ ❑ ❑ ❑ C I <br /> E Ll <br /> CI ❑ ❑ ❑ ❑ ❑ ❑ CI <br /> ❑ ❑ ❑ ❑ ❑ ❑ CI <br /> r ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ CI <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pumped test water to marked barrels& recycled any remaining test water. <br /> All boots removed from secondary& left in the normal operating position. <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: Date:4.28.17 <br />