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A <br />4 SWRCB, January 2002 Page 1 of 8 <br />Secondary Containment Testing Report Form — FINAL DRAFT <br />7'hh Jurui 6 1toteric ad Jur uve by cornlrach.ra perji,rming periodic testing of UST secondarycontainment 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 />FacilityName: Norms 76 1 Date of Testing: 1 1/ 4/ 0 2 <br />Facility Address: 633 E. Victor Rd., Lodi CA 95240 <br />Facility Contact: Greg Wilson Phone: 209-367-1795 <br />Date Local Agency Was Notified of Testing: 10/8/02 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Oil Equipment Service <br />Pass <br />Technician Conducting Test: James P. Hesketh <br />+ <br />Credentials: IXCSLB Licensed Contractor U SWRCH Licensed Tank Tester <br />License TypeA , H a z, C61 , C1 0, C 5 7, C 21 License Number: 323417 <br />Manufacturer Traluing <br />Manufacturer Component(s) <br />_ <br />Date Training Fat ires <br />Pass <br />Fail <br />Ameron Pi e <br />1/31/04 <br />Corning Pipe Sumps <br />6 19 02 <br />.Owens <br />? Dispenser Pans <br />I V <br />Component <br />Pass <br />Fail <br />Tested <br />Not <br />Repairs, <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />T1 -Annular Su er <br />U <br />U <br />I V <br />U <br />Dis2 Pan <br />1&2 <br />xj <br />U <br />U <br />U <br />T2 -Annular Mid rade <br />(JU <br />Lk <br />U <br />Disp Pan <br />3&4 <br />V <br />U <br />U <br />U <br />T3 -Annular Reg <br />U <br />U <br />UK <br />U <br />Disp Pan <br />5&6 <br />X1 <br />U <br />U <br />U <br />Pipe Sump Su er <br />lx <br />U <br />U <br />J <br />Disp Pan <br />7&8 <br />Xj <br />U <br />U <br />U <br />Sump Mid rade <br />Iii <br />U <br />U <br />U <br />Req fill <br />spill <br />U <br />xi <br />U <br />U <br />.Pipe <br />Pipe Sump Reg <br />!X <br />U <br />U <br />U <br />Midgrade <br />Fill Spill <br />U <br />N <br />U <br />U <br />Second Pi a Su er <br />lx <br />U <br />U <br />U <br />jSuper Fill Spill <br />U <br />Xj <br />U <br />U <br />Second Pipe MidgradE <br />ff <br />I U <br />U <br />U <br />U <br />U <br />U <br />U <br />Second Pipe Reg <br />(X <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />U <br />u I <br />U <br />U <br />U <br />U <br />U <br />U <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in thi document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: <br />11/4/02 <br />eS Qe, s( <br />