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SWRCB,January 2002 Page 1 of 10 <br /> Secondary Containment Testing Report Form <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, and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas 4 Less Date of Testing: Jan.30-31,2007 <br /> Facility Address: 3408 Manthey Rd. WO# 06-0504 Time: 09:00-17:00(30`)07:00-1700 -' <br /> Facility Contact: Gilbert Silva Phone: 209-858-0101 Ext 319 <br /> Date Local Agency Was Notified of Testing : January 26,2007 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Corp 1100 North J Street Tulare,CA 93274 <br /> Technician Conducting Test: John Ellis(ICC Service Tech Cert#0873833-UT expires 11-18-08) <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61/D40 HAZ License Number: 304147 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Environ Piping and Testing 5/08 <br /> OPW Piping and Testing <br /> Incon Testing 5/08 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> LO-Tank to UDC 9-10 X ❑ ❑ X LO Piping Sump X ❑ ❑ X <br /> LO-UDC 9-10 to 7-8 X ❑ ❑ X HO Piping Sump X ❑ ❑ X <br /> LO-UDC 7-8 to 5-6 X I ❑ ❑ I X LO Fill Sump X ❑ ❑ ❑ <br /> LO-UDC 5-6 to 3-4 X ❑ ❑ X HO Fill Sump X ❑ ❑ ❑ <br /> LO-UDC 3-4 to 1-2 X ❑ ❑ ❑ UDC 12 X ❑ ❑ ❑ <br /> HO-Tank to UDC 9-10 X ❑ ❑ X UDC 34 X ❑ ❑ X <br /> HO-UDC 9-10 to 7-8 X ❑ ❑ X UDC 56 X ❑ ❑ X <br /> HO-UDC 7-8 to 5-6 X ❑ ❑ X UDC 78 X ❑ ❑ X <br /> HO-UDC 5-6 to 3-4 X ❑ ❑ X UDC 910 X ❑ ❑ X <br /> HO-UDC 3-4 to 1-2 X ❑ ❑ ❑ Split Annular X ❑ ❑ ❑ <br /> Regular Fill Bucket X ❑ ❑ ❑ Regular Vapor Bucket X ❑ ❑ ❑ <br /> Premium Fill Bucket X ❑ ❑ ❑ Premium Vapor Bucket X ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Testing water was returned to the test trailer holding tank. <br /> LO(low octane secondary pipe) HO(high octane secondary pipe) <br /> UDC(under dispenser containment) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knoo,jedge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br /> r <br />