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Page 1 of 8 <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> 77da fin nt Ia Ira vtdedfi,r uve try cnntracnnv perfiirming periodic testing of U.ST.vecondary containment.systems. Use the <br /> appropriate pages of this form to report results far all components tested. 77te completedform,written test prom resnd <br /> printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory a en <br /> 1. FACILITY INFORMATION <br /> FaciiityNarne: Three Palms Grocer Date of Testing: 11 /21 /02 <br /> FacilityAddress: 6732 E. Waterloo Rd. Stockton CA 95215 <br /> Facility Contact: Rud Phone: 209-931.-6048 <br /> Date Local Agency Was Notified of Testing: 10/8/02 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil E ui ment Service _ <br /> Technician Conducting Test: James P. Hesketh <br /> Credentials: 6ICSLB Licensed Contractor U SWRCB Licensed Tank Tester <br /> License Type:A.Ha C61 D40 C10 C57 License Number: 323417 <br /> Manufacturer Tralaine <br /> Manufacturer Com nests Date Trainin fres <br /> ? Glass Clad Steel Tank N/A <br /> ? Galss Clad Steel Pipe Sumps N/A <br /> Western Fiber lass Dispenser Pans 6/19/04 <br /> 3. SUMMARY OF TEST UESULTS <br /> Not Repairs C <br /> omponentRepairs <br /> Component Paas Fail Tested Made Mede <br /> RPQ/Plii-; Annular A- u u u <br /> Reg pipe qu U u u u <br /> Li u u u <br /> Re dis an IX Ll U -i Uj <br /> Plus dis an I% U U U Li <br /> U u Li 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 U L1 U U U U U <br /> U U u u U U u u <br /> u u u u U u u u <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document at^accurate and in full compliance with legal requirements <br /> Technician's Signature: - Date: 11 /21 /02 <br /> ,)lines P. Hesketh <br />