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SWRCB, January 2002 Page 1 of 7 <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: 11/30/2010 <br />Facility Address: 15100 N. Thornton Road Lodi CA, 95242 <br />Facility Contact: Holly Marlowe Phone: 209-339-4066 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Jones Covey Group,Inc. <br />Technician Conducting Test: Edwin Coreas <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: License Number: <br />Manufacturer Training <br />Manufacturer Component(s)) Date Training Expires <br />Incon TS-STS <br />3. SUMMARY OF TEST RESULTS <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 11/30/2010 <br />