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SWRCB,January 2002 5 200/ Page I of 10 <br /> FEB 0 <br /> Secondary Containment Testing Report Form <br /> This fora,is intendedfor use by contractors performing periodic testing of USTsecondwy containment systems. Use the <br /> appropriate pages of this form to report results far all components tested The completedform, 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. FACII. TY INFORMATION <br /> Facility Name: Gas 4 Less Date of Testing: Jan.30-31,2007 <br /> Facility Address: 3408 Manthey Rd. WC+# 06-0504 Time: 09:00-1.7:00(30`')07:00-1700 (31'-V) <br /> Facility Contact: Gilbert Silva IPhone: 209-858-0101 Ext 319 <br /> Date Local Agency Was Notified of Testing: January 26,2007 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> C2m <br /> 2any Name: Franzen-Hill Colp 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 –7 SWRCB Licensed Tank Tester <br /> License Type: A,B,G61/D40 HAZ License Number: 304147 <br /> M ul'acture Tr inin <br /> Manufacturer Component(s) Date Trainigg Expires <br /> Environ Piping and Testing 5/08 <br /> OPW Piping and Testing <br /> Incon Testing 5/08 <br /> Cadwell Testin <br /> I SUMMARY OF TEST RESULTS <br /> Component Fsss Fail Not Repairs Not Rcpalrs <br /> p Tented Made Component paw Fail Tested I Made <br /> LO-Tank to UDC 9-10 X rl ❑ X LO Piping Sump X ❑ ❑ X <br /> LO-UDC 9-10 to 7-8 X ❑ n X HO Piping Sump X — n X <br /> LO-UDC 7-8 to 5-6 X n ❑ X LO Fill Sump X p ❑ ❑ <br /> LO-UDC 5-6 to 34 X ❑ X HO Fill Sump X ❑ ❑ c <br /> LO-UDC 3-4 to 1-2 X ❑ ❑ ❑ UDC 12 X ❑ ❑ 1 ❑ <br /> HO-Tank to UDC 9-1.0 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 Ll ❑ X UDC 78 X ❑ ❑ X <br /> HO-UDC 5-6 to 34 X ❑ ❑ X UDC 910 X ❑ ❑ X <br /> HO-UDC 3.4 to 1-2 X ❑ Q ❑ Split Annular X ❑ ❑ <br /> Regular Fill Bucket X ❑ ❑ Regular Vapor Bucket X ❑ ❑ ❑ <br /> Premium Fill Bucket X El [10 Premium Vapor Bucket X 11 El <br /> If hydrostatic testing was performed,describe what was douse with the water after completion of tests: <br /> Testing water was returned to the test trailer holding tank. <br /> L4 ow octane second pipe) !jQfth octane secondary pipe) <br /> UDC(under dispenser containment) <br /> CER]IFICATiON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the best of my know edee,Aefacts stated in this document are accurate and Infull co»rpawyce wdfit legal requhmneaos <br /> Technician's Signature:' Die: <br /> —P, <br /> I <br />