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MAY-30-2003 15:36 S 8 D TIME OIL CO SEATTLE 206 285 0639 P.01i02 <br /> Secondary Containment Testing Report Foirm <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment cyst iiiit"Else: <br /> appropriate pages of this form to report results for all components tested. The completed form,written test procedures, <br /> and printouts from tests(ffapplicable),should be provided to the facility owner/operatorfor submittal to the Jocnl <br /> regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Time Oil Co (jackpot F mart) DateofTesling: 2-27_03 <br /> Facility Address: 1434 W. Yosemite Manteca CA 95336 <br /> Facility Contact: Al Youn n Phone: 209-939-1792 <br /> Dam Local Agency Was Notified of Testing: 2-24-03 <br /> Name of Local Agency Inspector Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Eauioment Service <br /> TecluucianConducting Test: James P. Hesketh <br /> Credentials: )U CSLH Licensed Contractor 0 SWRCH Llcensedtank Tester <br /> License Type and#: 323417 1 A-Haz C-10 C-21 C-51 , C61 -D40 <br /> Training by Manufacturer <br /> Manufacturer Component& Date Treinine Extam <br /> Owens Corning Pipe Sum 6/19/02 <br /> L EEL E <br /> 3, SUMMARY OF TEST R,ESUI,TS <br /> Number of Tanks Tested: Mumber of A in Runs Tested: <br /> Number of Submersible Parnp,Sumps Tented' One __ IN�Uullmt�of MC of Overfill Boxes <br /> Tested: <br /> e <br /> Number of Fill Sum s Tested' <br /> Component ass Fail Commenb <br /> Q Q <br /> ❑ 13 <br /> D ❑ <br /> 0 F1 <br /> ❑ ❑ Post-It-Fax Note 7671 Dale 03r v a z <br /> To Co./ .From illi(1 L) ]5 <br /> 11 11N {U 00 ©C3 <br /> ❑ ❑ Co./� cva�tl L"6. <br /> ❑ ❑ Phone# Phone t< <br /> ❑ ❑ Fatg5�_ 6 —3 3 Faxa 2o('—Z —0(03 <br /> Q Q <br /> Q ❑ <br /> ❑ Q <br /> -.... - Datc: 2-27-03 _ <br /> Technician's Signature <br /> James esket December 2001 <br /> SWRCH <br /> ivinL r.vJG <br />