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SWRCB,January 2002 Page 1 of 18 <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 618 Date of Testing: 04/06/2023 <br /> Facility Address: 1501 N. Jack Tone Road <br /> Facility Contact: Manager Phone: (209) 599-4141 <br /> Date Local Agency Was Notified of Testing : 03/20/2023 <br /> Name of Local Agency Inspector(fpresent during testing): Christina Saeturn -San Juaquin County <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group Inc. <br /> Technician Conducting Test: Shawn Rodriguez <br /> Credentials: 1VCSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A, B HAZ License Number: 804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon Level 4 1021753712 12/6/2024 <br /> ICC Service Technician 8412602 11/19/2024 <br /> Veeder-Root B47358 02/09/2025 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T1 Diesel STP - Hydrostatic [i? ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T4 87 STP - Hydrostatic 0' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T5 91 STP - Hydrostatic V ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T6 Auto Dsl STP - Hydrostatic [i? ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 14-15 - Hydrostatic 0' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 26M - Hydrostatic 11? ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T1 Dsl Secondary Line ❑ ❑ 5? ❑ ❑ ❑ ❑ ❑ <br /> T4 87 Secondary Line ❑ ❑ 11? ❑ ❑ ❑ ❑ ❑ <br /> T5 91 Secondary Line ❑ ❑ [11? ❑ ❑ ❑ ❑ ❑ <br /> T6 AutoDsl Secondary Line ❑ ❑ [a' ❑ ❑ ❑ ❑ ❑ <br /> T3-Dsl Secondary to Disp 25-30 ❑ ❑ 11? ❑ ❑ ❑ ❑ ❑ <br /> 26M to 26Sat Secondary Line ❑ ❑ 4 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Oil a er Seperator <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 infill compliance with legal requirements <br /> 1 <br /> Technician's Signature: Date:4/6/2023 <br />