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SWRCB,January 2002 Page 1 of 2 Secondary Containment Testing Report 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#61$ 1 Date of Testing: 5.11.17 Facility Address: 1501 N. Jack Tone Rd. Ripon, CA. 95366 Facility Contact: Manager Phone: (209)599-4141 Date Local Agency Was Notified of Testing: 05/03/2017 Name of Local Agency Inspector(f present during testing): N/A z ' 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group,Inc. J_ N Q 5 2 0 17 Technician Conducting Test: James Blaine Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Test License Type: A,B and Haz License Number:804431 Manufacturer Training Manufacturer Component(s) Date Training Expires INCON 1006583708 9.28.2018 ICC 8469775 7.15.2018 3. SUMMARY OF TEST RESULTS Component Pass Fail Not I Repairs Component Pass Fail Not Repairs Tested Made Tested Made Disp. 14/15 UDC x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Pumped to marked barrels&recycled any remaining test water. All boots removed from secondary&left in the normal operating position. 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:_ " Date:5.11.17