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SWRCB,January 2002 NW.W1 1%W Page J—of Secondary Containment Testing Report Form This fort is intended for use by contractors perforning periodic testing of UST secondary containment systems. Use the appropriate pages of thisform 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: Tracy Petro,Inc Date of Testing: 9-30-04 Facility Address: 3400 North MacArthur Drive, Tracy, CA 95376 Facility Contact: Karam Phone: 209-834-1220 Date Local Agency Was Notified of Testing: 9-21-04 Name of Local Agency Inspector(ifpreseni during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Dialysis North Technician Conducting Test: Greg Hartman Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: License Number: 03-1640 Manufacturer Training Manufacturer Component(s) D Date -raining Expires 3. SUMMARY OF TEST RESULTS PERMIT/SERVICES Compoaent Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made I Tested Made Secondary Pipe# I -91 X ❑ ❑ ❑ Fill Sump# I -91 X ❑ ❑ ❑ Secondary Pipe#2-87 X ❑ ❑ ❑ Fill Sump#2-87 X ❑ ❑ ❑ Secondary Pipe#3-Diesel X ❑ ❑ ❑ Fill Sump# 3-Diesel X ❑ ❑ ❑ Piping Sump# I -91 X 0 0 ❑ Spill Fill Box# 1 -91 X ❑ ❑ ❑ Piping Sump#2-87 X I ❑ 0 ❑ 1 Spill Fill Box # 2-87 X ❑ ❑ ❑ Piping Sump# 3-Diesel X ❑ ❑ ❑ Spill Fill Box# 3-Diesel X 0 ❑ ❑ UDC # 1/2 X ❑ 0 ❑ 0 ❑ ❑ ❑ UDC # 3/4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC#5/6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC a Ira x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ ❑ ❑ ❑ I ❑ ❑ I ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the ads stated,4x this document are accurate and in full compliance with legal requirements Technician's Signature- Date: 9-jC C y