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Ll� <br />SRCB, January 2002 Page 1 <br />Wof <br />Secondary Containment Testing Report Form — FINAL DRAFT <br />'l7il.v Juno tv haendcd Jur uve by contractors perfbrnttng 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 />FacilityName: Valley Pacific Cardloek Date of Testing: 1 31 03 <br />Facility Address: 1524 Fresno ave. Stockton CA <br />Facility Contact: Mike Eliason Phone: 209-948-9412 <br />Date Local Agency Was Notified of Testing: 1/29/03 <br />Name of Local Agency Inspector (ifpresent during testing): None <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Oil Equipment <br />Service <br />Fail <br />Technician Conducting Test: James P. <br />Hesketh <br />Pass <br />Credentials: K CSLB Licensed Contractor U SWRCE Licensed Tank Tester <br />License Type: A Ha z C61 /D40 C 1 0 C 5 7 License Number: 3 2 3 41 7 <br />_ <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) <br />Date Training Expires <br />Modern Welding <br />Tank <br />6/10/04 <br />Containment Solutions <br />Sum <br />6/19/04 <br />Environ <br />---Pipe <br />Pi]2e <br />3/19/04 <br />Environ <br />Dispenser Pans <br />3/19/04 <br />3. SUMMARY OF TEST'RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fall <br />Not <br />Tested <br />Repairs <br />Made <br />Tank Annular <br />LX <br />U <br />o <br />U <br />U <br />U <br />U <br />U <br />Pipe Sump <br />(j <br />U <br />6 <br />IJ <br />U <br />U <br />U <br />U <br />Second Pipe #1 <br />L <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />Second Pipe #2 <br />LX <br />U <br />U <br />_j <br />U I <br />U <br />U <br />U <br />#1 Staelite VDC <br />LX <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />#1&2 Disp VDC <br />LX <br />Ll <br />Li <br />U <br />U <br />U <br />U <br />U <br />#2&3 Sat. VDC <br />LX <br />Ll <br />U <br />U <br />U <br />U <br />U <br />U <br />#3&4 Dis . <br />U <br />LX <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />LI <br />U <br />Ll I <br />U <br />U <br />U <br />lJ <br />U <br />u <br />U <br />U <br />U <br />U <br />U <br />U <br />u <br />u <br />u <br />U <br />u <br />u <br />u <br />U <br />u <br />u <br />u <br />U <br />U <br />u <br />u <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 docume mar ccu►ate and in full compliance with legal requirements <br />Technician's Signature: Date: 1/31 /03 <br />Ja sketh <br />