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SWRCB,January 2002 Page 1 of 8 <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> 'tide J..nu 1,bncnded JLr use by c—ara,tar,perJin-ming perlwlic testing of UST secondary containment systems. Ute 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(lf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Jackpot Food Mart I Date of Testing: 10/21 /02 <br /> Facility Address: 1434 W. Yosemite Manteca, CA <br /> Facility Contact: Alfred YounanPhone: 209-239-1792 <br /> Date Local Agency Was Notified of Testing : 10 /8 Z 0 2 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Equipment Service <br /> Technician Conducting Test: James P. Hesketh S <br /> Credentials: IXCSLB Licensed Contractor U SWRCR Licensed Tank Tester <br /> License TypeA,Haz,C61 /D40 ,C-10,C21 ,C5 LicensaNumber: 323417 <br /> Manufacturer TrOulne <br /> Manufacturer Component(s) Date Trainin Ex ices <br /> Modern Welding Tanks 6/10/04 <br /> Ameron Piping 1 /31 /04 <br /> Bravo D' en r P ns 9/25/04 <br /> Owens Corning 'Pipe Sumps 6/19/04 <br /> 3. SUMMARY OF TEST/RESULTS <br /> Component Pus Fail Not Repel Component Psae Fall Not Repairs <br /> Tested Made Tested Made <br /> Reg Ann Space Int 11 U Reg Pipe Sump kl U U U <br /> Plus Ann Space IX LJ IJ Plus Pipe Sump U kl U U <br /> Super Ann Space IH U U U Super Pipe Sump XI U U U <br /> Disip Pan 1 &2 I# LI U 11 U U U U <br /> Disp Pan 3&4 LY U U U U U U I U <br /> Disp A7&8 <br /> Ix U U U U U U U <br /> Dis Qi U U U U U U U <br /> Re Sa U U U U U U U <br /> Plus IX U U U U U U U <br /> Su erIx 1i U U U U U U <br /> H U U U U u u u <br /> U U u I u u I U u U <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Tect medium pumped bark to tank on tact trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,rhe facts stated In this document are curate and In full compliance with legal requirements <br /> Technician's Signature: ''/ 'k�E2 <br /> Date: 10/21 /02 <br /> James P. Hesketh <br />