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a`rV0,1B,January 2002 f Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Linden Associated Growers Date of Testing: 11/10/05 Facility Address: 14175 E. Highway 26,Linden CA Facility Contact: Charlie Buselacci Phone: 209-931-4800 Date Local Agency Was Notified of Testing : Minu _ Name of Local Agency Inspector(if present during testing): t{ 3 ENVIRONMENT HEALTH 2. TESTING CONTRACTOR INFORMATION VLU Company Name: JP Petroleum Service Technician Conducting Test: Gaberial Garcia Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number: &11471 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular#1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC #1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC #2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 - ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the f st d in this document are Wcurate and in full compliance with legal requirements Technician's Signature: " Date: