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SWRCB,January 2002 0 Page I of 7 <br /> Secondary Containment Testing Report Form <br /> 1 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: PG&E Tracy I Date of Testing: 12/12/02 <br /> Facility Address: 24081 Mountain House Parkway Tracy WO# 111062 <br /> Facility Contact: Gary Pforr Phone: 925-674-6707 <br /> Date Local Agency Was Notified of Testing: 12/10/02 <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Corp 1100 North J Street Tulare, CA 93274 <br /> Technician Conducting Test: Felix Mendes <br /> Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61/D40 HAZ License Number: 304147 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin, Fx fires <br /> Environ Piping and Testing 10/03 <br /> Total Containment Piping and Testing 10/03 <br /> Incon Testing 09/04 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> hn Or I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> f}nn.n 1 qr Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> SPoc,n ckr.r ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> 5eC&,1 d c+r 42- ❑ ❑ 141 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5� m #7 ❑ It ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10106 , 1-2— ❑ ❑ 1j ❑ ❑ ❑ ❑ ❑ <br /> U C 1-4 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ I I ❑ I ❑ 1 ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> ZS ctils I�€+ Gn Sife ICw <Httcrrer t*: r-emarc .1i d r-- <br /> CERTIFICATION <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: <br />