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Page 1 of 7 <br /> Secondary Containment Testing Report Form <br /> This./orm is intended for use by contractors performing 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(rf applicable), should he provided to the facility owner/operator for submittal to the heal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name= Rancho San Miguel Date of Testing: March.21,2006 <br /> Facility Address: 1409 Airport Way Stockton WO#03-0405 Time; 9:00 am <br /> Facility Contact: Gilbert Silva Phone: (209)983-9650 <br /> Date Local.Agency Was Notified of Testing: March 16,2005 <br /> Nance of Local.Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATLON <br /> Com any Name: Franzen-Hill.Corp 1100 North J Street Tulare, CA 93274 <br /> Technician Conducting Test: John.Ellis <br /> Credentials; x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A,,B,C-ti 1/D40 H.A,Z License Number: 304147 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> Environ. Piping and Testing 12/07 <br /> Total Containment Piping and Testing 9107 <br /> Incon Tegtin 11/07 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> P Tested MadeCo�tpunent Pass Fail Tested Made <br /> UDC 34 X X <br /> UDC 56 x X <br /> If hydrostatic testing was performed,describe what was done with the water alter completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my know dg, the facts stated in this documm� are acrarule and m full eonT ience with legal requironenls <br /> Technician's Signa. Date: <br />