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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 I Date of Testing: 3/03/11 <br /> Facility Address: 15100 N.Thornton Rd.Lodi,CA 95242 <br /> Facility Contact: Manager Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group <br /> Technician Conducting Test: <br /> Credentials: x CSLB Licensed Contractor x SWRCB Licensed Tank Tester <br /> License Type: License Number: 03-1652 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> [Franklin Fueling Incon 8/21/2011 <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 x <br /> UDC#14/15 x <br /> UDC# 16/17 x <br /> UDC#21 Main x <br /> UDC#21 Satellite x <br /> T-3 Diesel STP x <br /> 91 Fill Bucket x <br /> 87 Secondary x <br /> 91 Secondary x <br /> Diesel Secondary x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: 3/3/2011 <br />