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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 test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pilot-Flying J#617 1 Date of Testing: 8/27/2014 <br /> Facility Address: 15100 North Thornton, Lodi, Ca, 91761 <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing: 8/4/2014 <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group,Inc. <br /> Technician Conducting Test: Arturo Perez Jr <br /> Credentials: ®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 /> Incon TS-STS 01-20-2016 <br /> ICC 8061052 01-26-2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 13 ® ❑ 0 ❑ ❑ ❑ ❑ <br /> 91 STP ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank#3-87 STP ® ❑ ❑ ❑ lu ❑ ❑ ❑ <br /> Ll ❑ ❑ ❑ J ❑ ❑ 1 ❑ <br /> ❑ ❑ 0 ❑ 1j ❑ ❑ ❑ <br /> F1 ❑ ❑ 0 ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> *Water was recycled in water trailer for reuse. <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 compli c a Cg# <br /> i <br /> TT E D <br /> Technician's Signature: Date:8/27/2014 <br /> SEP 0 8 21 <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />