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L j-L-- <br /> '108 <br /> SVAKCB,lanuaty 2002Page_of <br /> ELN V 10 11 1 L-'�i� 1 1 <br /> =ewe 1 <br /> S�, r'y"t 4ntainment Testing Report Form <br /> Thu form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report resuIts for all components tested The completed form,written test procedures, and <br /> printouts from tests('(applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACELITY TWORMATION <br /> Facility Name: Ramos Oil Company—French C Date of Testing: 12/17/08 <br /> Facility Address: 10842 S.Harlin Road,French Camp Ca 95231 <br /> Facility Contact: Dave Nelson Phone: 916-371-2570 <br /> Date Local Agency Was Notified of Testing: 12/15/08 <br /> Name of Local Agency Inspector('(present during testing): <br /> 2. TES CONTRACTOR UWORMAT-FON <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test Gabe Garcia <br /> Credentials: x CS LB Licensed Contractor El SB Licensed Tank Tester <br /> License Type: A License Number- 811471 <br /> Manufacturer T <br /> Manufacturer Component(s) Date Training f2M:ires <br /> 3. SUMMARY OF TEST RESULTS <br /> NotRepairs Not liepairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annular 1 0 0 x 0 UDC4A& 5A x ❑ E] 0 <br /> Line I x ❑ 0 0 LJDC 5 x El 0 0 <br /> Line 2 x 0- 0 . 0 0 - 0 0 0 <br /> Line 3 x El El 0 0 0 0 0 <br /> Line 4 x ❑ 0 0 0 0 0 0 <br /> Line 5 x 0 0 0- 0 0 0 0 <br /> Sump I x El 0 . 0 0 0 0 0 <br /> UDCIA x n E) El 0 0 ri 0 <br /> LJDC 1&2 x El 0 ❑ 0 0 0 0 <br /> UDC2A&3A x El 0 0 0 0 0 0 <br /> UDC3&4 x 0 ❑ 0 El 1 0 - 0 0 <br /> El 0 0 0 DJ El I- 0.,_J_El j <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN REspoNSEBLE FOR CONDUCTING T TESTING <br /> To the best ofmy knowledge,the fa stated In Wv docunwd are accurate and In full compliance with legal requirements <br /> Technician's Signature: WOoel�� Date: <br />