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Secondary Containment Testing Report Form Page 1 of 8 <br /> 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, <br /> and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local <br /> regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: Time Oil Co. (Jackpot Food Mart Date ofTestin <br /> Facility Address: 1434 W. Yosemite Manteca CA 95336 g' 2-27-03 <br /> Facility Contact: Al Younan Phone: <br /> Date Local Agency Was Notified of Testing 2 0 9- <br /> -03 939 <br /> - <br /> L <br /> Name of Local Agency Inspector Present 2-24 <br /> ------------------ <br /> 2. TESTING CONTRACTOR INFORMATION MAR U <br /> Company Name: Oil Equipment Servic NVI <br /> Technician Conducting Test: James P. Hesketh P <br /> Credentials: X1 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type and#: 323417 A-Haz C-10 C-21 , C-51 , C61 -D40 <br /> Training by Manufacturer <br /> Manufacturer Component(s) LateTrainin Ex fres <br /> Owens Cornin Pipe Sum 6/19/02 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: I Number of Pi mi Runs Tested: <br /> Number of Submersible Pum Sum s Test ed One lunber of U <br /> NDC Boxes Tested: <br /> Number of Fill Sum s Tested Number of Overfill Boxes Tested: <br /> Component Pass Fail Comments <br /> -21115 Pipe S ❑ <br /> ❑ Ca <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ o <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ - <br /> Technician's Signature: Date: 2-27-03 <br /> Jamers esket <br /> SWRCB <br /> December 2001 <br />