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SWRC`B,January 2002 *"W Page Page i of 1 <br /> Secondary Cote Itainment Testing Repdit,Fot-MH <br /> This form is intended for use by contractors perf<.,wing periodic testing of UST sec .contdijTfz(ffAttW. Use the <br /> appropriate pages of this form to report results fiir all components tested The compleWXgrFAprocedures, and <br /> printouts from tests(if applicable), should be pro,,.led to the facility owner/operator for submittatto tTielkal regulatory agency. <br /> 1. FACMITY INFORMATION <br /> Facility Name: Tracy Petro Date of Testing: 1-2-08 <br /> Facility Address: 3400 N. Mac Arthur 7 dcy,CA. 95376 <br /> Facility Contact: Karam I Phone: 209-834-1220 <br /> Date Local Agency Was Notified of Testing: 12-5-07 <br /> Name of Local Agency Inspector(if present dinag testing): Michelle Henry <br /> 2. TESTING C:_sNTRACTOR INFORMATION <br /> Company Name: Dialysis North <br /> Technician Conducting Test: Greg Hartm i <br /> Credentials: D CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: License Number: 03-1640 <br /> i Manufacturer Training <br /> Manufacturer Component(s) Date Traininp Expires <br /> 3. SUMM:{,RY OF TEST RESULTS <br /> Component Pass Fail ' Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Space (Brine Filled) ❑ ❑ i�: X ❑ Fill Riser Sump-91 X ❑ ❑ ❑ <br /> Secondary Pipe-91 X ❑ i/ ❑ ❑ Fill Riser Sump-87 X ❑ ❑ ❑ <br /> Secondary Pipe—87 X ❑ ❑ ❑ Fill Riser Sump-Diesel X ❑ ❑ ❑ <br /> Secondary Pipe-Diesel X ❑ ;t. ❑ [1 Spill/Fill Box#1- 91 X ❑ ❑ ❑ <br /> Piping Sump-91 X ❑ �_,; ❑ E] Spill/Fill Box#2-87 X ❑ ❑ ❑ <br /> Piping Sump-87 X F ❑ ❑ Spill/Fill Box#3-Diesel X ❑ ❑ ❑ <br /> Piping Sump-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#1/2 X Ci 4 ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#3/4 X Ij i ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC It 5/6 X ❑ ! ❑ L7 ❑ ❑ ❑ ❑ <br /> UDC#7/8 X ❑. ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe H t t was done with the water after completion of tests <br /> Left sump test water in 3-55 gallon drums. <br /> t4 <br /> Gr <br /> CERTIFICATION OF TECHNIC kN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in i is document are accurate and in full compliance with legal requirements <br /> --L—u-1) <br /> Technician's Signature: UIV Date:__ <br />