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SWRCB.January 2002 - s <br /> Page ] of 7 <br /> Secondary Containment Testing Report Form <br /> 97rar form is intended for use by contracra s performing periodic testing of UST secondary contaimnent systems. U.ve the <br /> appropriate page"of this form to report results for all Component,"tested The completed form, written test prom,,dures, an <br /> printouts from tests(if applicable),should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACH ITT MORMATION <br /> Facility Name: Rancho San Migue] Date of Testing: Nuv.30th 2005 <br /> Facility Address: 610 South Cherokee Lane Lodi Ca.95240 W09 03-0119 Time: 8:30 am <br /> Facility Contact: Dermis Cove Phone: (209)957-2555 <br /> Date Local Agency Was Notified of Testing: November 2e 2005 <br /> Name of Local Agency Inspector(if present during testing): None Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Copp i 100 North J Street Tulare,CA 93274 <br /> Technician Conducting Test: John Fllis <br /> Credentials: x CSLB Licensed Contractor E SWRCB Licensed Tank Tester <br /> License Type: A,13,C-61/D40 HAZ License Number: 304147 <br /> Manufacturer Trainiae <br /> Manufacturer Co s Date Training Expires <br /> Environ p;,;,,and Testin 10/07 <br /> Total Containment Pipig and Testmg <br /> Incon Teqin 8/07 <br /> Cadwell Testing <br /> 1 SUMMARY OF TEST RESULTS <br /> Component Paas Fail NM t2°�'", Component pis Felt Not R°pairo <br /> Tested Made TgKd Made <br /> Split Tank Annular X ❑ ❑ ❑ UDC 1-2 ❑ X ❑ ❑ <br /> 87 Product Secondary X ❑ ❑ ❑ UDC 3-4 ❑ X ❑ ❑ <br /> 87 Vapor Secondary X ❑ 0 ❑ UDC 5-6 X ❑ ❑ <br /> 87 Vent Secondary X r, ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Product Secondary X ❑ ❑ 103 <br /> ❑ ❑ ❑ ❑ <br /> 91 Vent Secondary X ❑ ❑ ❑ ❑ ❑ fl ❑ <br /> 87 Fill Sump X ❑ ❑ ❑ =D1 91 Fill Sump X J ❑ ❑87 Piping Stump X ❑ ❑ p 91 Piping Sunp X ❑ C p 87 Spill Bucket X 0 ❑ ❑91Spill Bucket X ❑ ❑ ❑ <br /> If hydrostatic testing was performed„describe what was done with the water after completion of tests: <br /> Returned to storage <br /> CERTIFICATION OF TECHNICIAN RESPONSIME FOIL CONDUCTING TFM TESTING, <br /> TO the beet of hny knowledge,the facts stated in this document are accurate and In fill eotnppance with&waal trgu irements <br /> Technician's Signature:�/��¢ � Date: L'"y ( 0. <br />