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SWRCB,January 2002 Page of 8 <br /> Secondary Containment Testing Report Form— FINAL DRAFT <br /> 'I'Idv .„ t., buc.,dcd Jbr uve by cunlruclury perJLrodng perlodle testing of I/,ST.vecondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completedform,written test procedures,and <br /> printouts from tests(ffapplicable),should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Jackpot- Food Mart Dale of Testing: 10/21 /02 <br /> FacilityAddress: 1434 W. Yosemite Manteca, CA <br /> Facility Contact: Alfred Younan Phone: 209-239-1792 <br /> Dale Local Agency Was Notified of Testing : 10/8102 <br /> Name of Local Agency Inspector pfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Equipment Service <br /> Technician Conducting Test: James P. Hesketh t <br /> Credentials: LKCSLB Licensed Contractor U SWRCR Licensed Tank Tester <br /> License TypeA,Haz,C61 /D40,C-10,C21 ,C5 Licenso,Number: 323417 <br /> Manufacturer Tralaine <br /> Manufacturer -Component(s) Date Training Expires <br /> Modern Welding Tanks 6/10/04 <br /> Ameron Piping 1 /31 /04 <br /> Bravo Di*pgnser Pan 9/25/04 <br /> Owens Corning Pipe Sumps 6/19/04 <br /> 3. SUMMARY OF TEST'YIESULTS <br /> Component Pass Fall Not Repairs, Component Pare Fall TNot Repairs Mada <br /> Tested Made <br /> Reg Ann Space UI 11U Re Pipe Sum kl U U U <br /> Plus Ann Space IS _LJ_ U Plus Pipe Sump U kl U U <br /> Super Ann Space Ix U U U Super Pipe Sump KI U U U <br /> Disp Pan 1 &2 1A U U -i U U U U <br /> Disp Pan 3&4 I}I I U U U I U U U U <br /> Disp Pan 5&6 U U U U U U U U <br /> Disp Pan 7&8 IH I U U U U U U U <br /> Reg Sec Pipe I}1 LLJ U U U U U U <br /> Plus Sec Pipe IH U U U U U U U <br /> Super Sec Pipe U U U U U U U U <br /> U u I 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 /> TpGt mpAinm pumped hack to tank on test trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated In this document arepecurate and in full compliance with legal requirements <br /> Technician's Signature: <br /> AJa <br /> (� 14Date: 10/21 /02 <br /> es P. Hesketh <br />