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SWRCB,January 2002 • • Page of 8 <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> '17ds Ji.rrn i,InWndcdfur uve try cuntraclurs perJurming perlr.dic levNng of UST.veeondary rontainment.systems. Use the <br /> appropriate pages ofthis form to report resultsfor all components tested. The completedform,written test procedures,and <br /> printouts from tests(ifapplicable),should be provided to the facility owner/operalorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: <br /> Facility Address: 1400 E. Highway 88 Lockford CA 95327 <br /> Facility Contact: Randy Haywood I Phone: 209-727-5442 <br /> Date Local Agency Was Notified of Testing: 10/8/02 <br /> Name of Local Agency Inspector(rfpresent during testing): None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 011 Equipment Service <br /> Technician Conducting Test: James P. Hesketh _ <br /> Credentials: K CSLB Licensed Contractor U SWRCB Licensed Tank Tester <br /> License Type:A.Haz C61 D40 C10 C57 1 LicensoNumber: 323417 <br /> Manufacturer Traluine <br /> Manufacturer Component(s) Date Training Expires <br /> Modern Welding Tanks 6/10/04 <br /> Co nt inment Solutions Pipe Sumps 6/19/04 <br /> 1 /31 /04 <br /> 9/25/04 <br /> 3. SUMMARY OF TEST/RESUI T6 <br /> Not Repairs <br /> Component Pass Fail Testeot dRepairs,i Made Component Pass Fail Tested Made <br /> Rag Annular Lk .0 U Pan 1 &2 M U U U <br /> Super r a I tJ U U pisp Pan 3&4 W U U U <br /> Pliiq Annular _LL U u Disp Pan 5&6 44 _UL U U <br /> Rea pipe SUMDU LX U -i Disp Pan 7&8 N U U U <br /> Super pipe sump U Lj U U U U U U <br /> Plus Pipe sump U Ll u U U U U U <br /> U U u U u u u <br /> Li u U U u U u <br /> Plus second pipe UL U U U U U U U <br /> IJ U U U U u u U <br /> U U u u U u u u <br /> U u u u u U u I u <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test medium pumped back to tank on test trailer. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this documer re accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11 /13/02 <br /> T/91 es P. Hesketh <br />