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Received <br /> SWRCB,January 2002 11/29/2022 Page 1 of 22 <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(f 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 Lodi Date of Testing: 10/28/2022 <br /> Facility Address: 15237 N. Thornton Rd. <br /> Facility Contact: Site Manager Phone: (209) 339-4066 <br /> Date Local Agency Was Notified of Testing : 10/20/2022 <br /> Name of Local Agency Inspector(fpresent during testing): Not Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group, Inc. <br /> Technician Conducting Test: Shawn Rodriguez <br /> Credentials: VCSLB 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 /> Franklin Fueling Incon Level 4- Sump Tester#1021753712 11/18/2022 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T1-87 STP Sump 4 ❑ ❑ ❑ 87 Syphon Secondary [I' ❑ ❑ ❑ <br /> T2-87 STP Sump 11? ❑ ❑ ❑ UDC 1/2 ❑ IV ❑ ❑ <br /> T3-87 STP Sump IV ❑ ❑ ❑ UDC 3/4 IV ❑ ❑ ❑ <br /> T4-87 STP Sump 5? ❑ ❑ ❑ UDC 5/6 ❑ CI' ❑ ❑ <br /> T5-91 STP Sump 11? ❑ ❑ ❑ UDC 7/8 11? ❑ ❑ ❑ <br /> T1-87 Fill Sump J? ❑ ❑ ❑ UDC 9/10 IV ❑ ❑ ❑ <br /> T2-87 Fill Sump 5? ❑ ❑ ❑ UDC 11/12 V ❑ ❑ ❑ <br /> T3-87 Fill Sump 11? ❑ ❑ ❑ UDC 13 11? ❑ ❑ ❑ <br /> T4-87 Fill Sump IV ❑ ❑ ❑ UDC 14/15 II' ❑ ❑ ❑ <br /> T5-91 Fill Sump 5? ❑ ❑ ❑ UDC 16/17 IV ❑ ❑ ❑ <br /> 87 Product Secondary [V ❑ ❑ ❑ JUDC 18 C7' 1 ❑ 1 ❑ ❑ <br /> 91 Product Secondary [V ❑ ❑ ❑ 1 Diesel Secondary from Trans sump to UDCs [V I ❑ I ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Returned to Holding Tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this darziment are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 10/28/2022 <br />