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SWRCB,January 2002 Page—L of 8 <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> Ila.,Joan h Inicndcd fur ure I y cuntractury per/i.rming periodic testing of UST secondury containmentsystems. Use the <br /> appropriate pages of thisforin to report results for all components tested. The completed form, written test procedures,and <br /> printouts from tests(if applicable),should be provided to thefacility owner/operatorforsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: Valley Pacific Cardlock I Date of Testing: <br /> Facility Address: 3550 S. Highway 99 Sto kt n <br /> Facility Contact: Mike Eliasori Phone: 2ng-948-9412 <br /> Date Local Agency Was Notified of Testing: 10/8/02 <br /> Name of Local Agency Inspector(ifpresent during testing): NOR <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Equipment Service <br /> Technician Conducting Test: James P. Hesketh _ <br /> Credentials: pi CSLB Licensed Contractor U SWRCB Licensed Tank Tester _ <br /> License Type:A,Haz C61 D40 C10 C57 License Number: 323417 <br /> Manufacturer Tralaine <br /> Manufacturer Component(s) Date Training Expires <br /> Modern Welding Tank 6/10/04 <br /> Ameron Pipe 1 /31 /04 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fall Not Repairs <br /> Tested Made Tested Made <br /> Reg/Red Diesel Ann -.L�- 'Ll Lj u u U u u <br /> Rog RPrr)nr9 Pipe I= U u U u u <br /> Diesel Second Pipe U U U U U U U U <br /> U U i u U U u <br /> Diesel Pi a Sump U U U U U U U U <br /> Reg fill spill tub U Lk U U U U U U <br /> Diesel fill spill t bU Ix U U U U U U <br /> u U U U u U U <br /> U U U U u U u U <br /> U U U u U U u u <br /> U U u u U U U u <br /> U I u u I u Ll I U U 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 document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 12/5/02 <br /> ames p. Hesketh <br />