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SV;RC13.Jamwv 2002 <br /> Secondary Containment Testing polrt `air � < _ nJ06 <br /> This form is,intended for use by contractors performing periodic testing of LIST secondary comaintnettt syste>rrsk i r ;',dT HEALTH <br /> appropriate pages of this form to report results for all components tested The completed form,written test procel pr torte ;._ <br /> printouts from tests(if applicable),should be provided to the facility ownerloperawr for submittal to the local regttl=j09AR ICES <br /> 1. FACILITY INFORMATION <br /> Facility Name: RaauQbo San M el Date of Testita : Ncw.30*2005 <br /> Facility Address: 1409 Airport Road Stockton Ca. WC .03-0405 Ti-mc: 12:00 pm <br /> Facility Contact: Dennis Cove Phone: (209)957-2555 <br /> Date Local,Agency Was.Notified of Testing: November 2e 2005 <br /> Name of Local,A,Vncy Inspedot(ff,present during testing): Notre Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co my Name: Franzen-hill Carp 1100 North J Street Tulare,CA 93274 <br /> Technician Conducting'fest: John Ellis <br /> Credentials: x CSLB Licensed C-ontractvr L SWRCB Licensed Tank Tester <br /> License Type: A,3,C-61lD40 HAZ License Number: 304147 <br /> Manufacturer Traillft <br /> Manufacturer convonent(sj Date TT aining Expires <br /> Environ Pipmg and Tmtg 10107 <br /> Total Containment P! in and Testing <br /> 8I07 <br /> In= Te <br /> Cadwell Te <br /> I SAY OF TEST RESULTS <br /> Not Ro airs <br /> CampoTtent Pass Fail TeRe Made paim Component Pass FailestTested 3[ade <br /> Split Tank Annular X ❑ ❑ ❑ UDC 1-2 X El- . .,[] ❑ <br /> 87 Product Secondary X ❑ ❑ ❑ LxDC 3 ❑ X El <br /> 87 Vapor Secondary X ❑ ❑ ❑ U7?C 5-5 ❑ X ❑ ■ <br /> 87 Vent Seeoudary X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Product Secondary X ❑ ❑ ❑ ❑ Q ❑ <br /> 91 Vent Secondary X ❑ ❑ i-t ❑ ❑ ❑ ❑ <br /> 87 Fill Sump X ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> 91 Fill Sump ° X ❑ ❑ ❑ 0 Cl ❑ ❑ <br /> 87 Piping Sump X ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Piping Sunp X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Spill. Bucket X ❑ ❑ ❑ ❑ ❑K. ❑ ❑ <br /> 91 Spill Bucket X ❑ ❑ v ❑ 0 ❑ 0 <br /> If hydrostatiic testing was perfontwd.desrrtibe what was done with the waxer after completion of tests: <br /> Retumed to stora e <br /> CERTMC.A''"QN OF TECHNICIAN RESPONSIBLE FOR CONDUCTTNG TWS TESTTPIG� <br /> To the best oftrty know! tke fads stated in ails document are accurate and in full cotn,pifance with legal rejulremmis <br /> Technician's Saga — — ? �1`���05~ <br />