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Nov, 15. 2005 8: 58AM Wei+ Star Environmental, Inc. No. 3742 P. 2 <br /> SWRCS,Jzudary 2002 <br /> 0 0 Page 1 of" <br /> : Secondary Containment Testing Report Form <br /> T7tis form is intended.for use by coruraciors performing periodic testing of UST secondary contaironent systems. Use the <br /> appropriate pages of this form to report result c for all components rested The completed.form, written test procedures, and <br /> Print outs from tests(if applicable), should he provided to the faeiliry owner/operator for submittal to the local regulatory agency. <br /> 1. FACTI,ITY INFORMATION <br /> Facility Name: escalon mini mart Date of Testing: 11/8105 <br /> Facility Address: 1097 E.Yosemite <br /> Facility Contact: bill T Phone: (209)838-1546 <br /> Date Local Agency Was Notified of Testing 1026-05 <br /> Name of Local Agency inspector(f prawnt during testing): dennis - <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Eco-;pany Name- WINC. <br /> Technician Conducting Test; DaNENVIRONMENTAL,niel Chavez <br /> Credentials_ CSLB Licensed Contractor x SWRCB Licensed'Tank.Tester <br /> License Type: A-HA2 License Number: 605142 <br /> Manufacturer Traipin� <br /> Manufacturer Component(s) Date Training Expires 1 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs 1Vot Re a <br /> Component Pass FaII (;aoponedt Pau Fall p ? <br /> r Tested Made _ Tested Made <br /> UDC 1/2 X Sill over 61191 vapor buck,et X <br /> UDC 3/4 <br /> CJ'DC 5/6 X <br /> ITDC <br /> 7/8 <br /> Annular.Tace X <br /> Thrbine sump 87 _ <br /> X <br /> Turbine sump 91 X -! <br /> Secondary product piping 87 X f <br /> Secondary product i ing 91 <br /> Spill over fill 87 vapor bu&:et X T <br /> S ill over fill 97 bucket X _ <br /> Spill over fill 91 bucket - .X _ <br /> If hydrostatic testing was performed,describe what was done with the water after campletion of tests: The water was put in a <br /> hazardous waste drum and(eft at the site. 1. 50 gallon drum. <br /> CERTII~ICATION OF TEC:HNICUN I:ESPONSIBLE FOR CONDUCTING THIS 'TESTING <br /> To the hest of my knowledge,the facts stated in this document are accurate and in frail compliance with legal requlrc heats <br /> Technician's Signature:-r�'c 'tL'l _,�'-� Date:_ <br />