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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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Pilot Flying J 618 Ripon Date of Testing: 06/15/2023 Facility Address: 1501 N. Jack Tone Rd. Facility Contact: Site Manager Phone: (209) 559-4141 Date Local Agency Was Notified of Testing: 06/09/2023 Name of Local Agency Inspector(ifpresent during testing): None 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group, Inc. Technician Conducting Test: Shawn Rodriguez Credentials: C,/CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B and Haz License Number: 804431 Manufacturer Training Manufacturer Component(s) Date Training Expires NOV Fiberglass Systems Secondary Pipe 05/22/2026 ICC 8412602 11/19/2024 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Diesel Syphon Secondary Line I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank 1 Diesel Secondary Line I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank 2 Diesel Secondary Line I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disp 27-28 Satellites Secondary 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Disp 29-30 Satellite Secondary I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Tank 4 87 Product Secondary 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: N/A CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in thxa da—ment are accurate and in full compliance with legal requirements Technician's Signature: Date:06/15/2023