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SWRCB,January 2002 Page of 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Pilot Flying J #617 Date of Testing: 9-18-2020 Facility Address: 15237 N. Thornton Rd. Facility Contact: Manager Phone: (209)339-4066 Date Local Agency Was Notified of Testing: 9-9-2020 Name of Local Agency Inspector(fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group,Inc. Technician Conducting Test: Jose Ochoa Credentials: ❑CSLB Licensed Contractor J SWRCB Licensed Tank Tester License Type: A,B and Haz License Number:804431 Manufacturer Training Manufacturer Component(s) Date Training Expires I N CO N TS-STS 8-23-21 1 CC 8004551-UT 10-28-2021 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made T-2 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-3 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-4 STP Sump x ❑ ❑ ❑ ❑ ❑ T-5 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-1 Fill Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-2 Fill Sump ❑ ❑ ❑ ❑ ❑ T-3 Fill Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-4 Fill Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-5 Fill Sump ❑ ❑ ❑ ❑ ❑ Udc 7-8 ® ❑ ❑ ❑ ❑ ❑ Ll Li Udc 13 ® El 11 El El El El El Udc 16-17 ® El 11 El 11 ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: RETURNED TO HOLDING TANK. 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: 9-18-2020