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J n 23 06 08: 16P Me Dotten 200533-2650 p. 1 <br /> a <br /> A1ltech <br /> 17759 Buttercup Circle <br /> a Sonora, CA 95370 <br /> 209-532-7320 <br /> Secondary Containment Testing Report Form <br /> 1. FACILITY INFORMATION <br /> Facility Name: Madsen's Dairy Date of Testing: Friday,January 06, 2006 <br /> Facility Address: 239 S. Stockton Rd.,Ripon CA 95358 <br /> Facility Contact: Bob Madsen I Phone: 599-3041 <br /> Date Local Agency Was Notified of Testing :Not sure at this point. <br /> LName of Local Agency Inspector(f present during testing): Willy Ng <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name. A][tech Petroleum Services <br /> Technician Conducting Test: Mike Dotten <br /> Credentials: El CSLB Licensed Contractor ®SWRCB Licensed Tank Tester <br /> License Type: A, Haz License Number:623541 <br /> _Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> Incon Sua!p Tester ! en cs; <br /> 7v;r " C- <br /> W-�-nFt 1 _ <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not I Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Diesel fills ill near the street) X ❑ Annular(shared) ❑ ❑ I ❑ <br /> Diesel UDC near the street 0 ❑ ❑ 1 ❑ [] ❑F7-❑ ElRegular f lls ill I ❑ I ❑ ❑ ElElRegular UDC - ❑ ❑ ❑ El1:1Diesel fills ilp 1�- ® ❑ ❑ ® ' F1 El E] ❑ <br /> Duesel UDC ❑ ❑ ❑ I El 0 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water from all tests was <br /> placed in a barrel that was already on site. The barrel was marked with a Hazardous Materials label and left on site. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the Paco stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: �� <br />