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Pagc 1 of 7 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic lesting of UST secondary containment systems, Use the <br /> appropriate pages of this farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts front tests (rf 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: March 22,2006 <br /> Facility Address: 3434 Manthey Street Stockton,CA WO# 118033 Time:8:00 am. <br /> Facility Contact: Gilbert Silva Phone: (209)944-4577 <br /> Date Local Agency Was Notified of Testing: March 16,2006 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> i <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Corp 1100 North J Street Tulare,CA 93274 <br /> Technician Conducting Test: iohn Ellis <br /> Credentials: x CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61;1)40 I-JAZ License Number: 304147 <br /> Manufacturer Trainine <br /> Manufacturer Com onent s Date Training Expires <br /> Environ Pi]2ing and T,-sting 12/07 <br /> Totat Containment Piping and T-sting 9/07 <br /> Incon Testing 11/07 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Component FP.99 <br /> Fail Not Repairs Not Repairs <br /> Component Tested Made Component Pass Fail Tested Made <br /> Split 'Tank Annular Space X Premuim Secondary 3 X <br /> Premium Fill Sump I X Regular Secondary 4 X <br /> Premium PiPing Sump x <br /> Re ular Fill Sum x <br /> Re ular Piping Sump x <br /> Premium Secondary 1 x <br /> Regular Secondary 2 X <br /> UDC 12 x <br /> UDC34 x <br /> UDC 5b x <br /> UDC 78 x <br /> UDC910 X <br /> If hydrostatic testing was performed. describe what was done with the water after completion of tests.- <br /> Water <br /> ests:Water returned to the storage tank on test trailer. <br /> CERTIFi<CATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signatur • L Date; v� �� <br />