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�s y <br /> 0 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, <br /> and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local <br /> regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Beacon#3641 Date of Testing: 7/31/02 <br /> Facility Address: 1210 East Hammer Lane Stockton,CA 95210 <br /> Facility Contact: Manager Sandy Huff Phone(209)477-3111 <br /> Date Local Agency Was Notified of Testing: 7/26/02 <br /> Name of Local Agency Inspector Present:None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Bonsall Petroleum <br /> Technician Conducting Test:Richard Cummings,Nick Patrick <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type and#: A,B,HAZ #682742 <br /> Training by Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> USTest UST2000P 12/03 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: 3 Number of Piping Runs Tested: 3 <br /> Number of Submersible Pump Sumps Tested: 3 Number of UDC Boxes Tested: 4 <br /> Number of Fill Sumps Tested:0 Number of Overfill Boxes Tested: 0 <br /> Component 7Pass Fail Comments <br /> T1 RU Annular T2 PLUSAnnular T3 SUAnnular <br /> L1 RU Containment Line X <br /> L2 PLUS Containment Line X <br /> L3 SU Containment Line X <br /> Tl RU Turbine Sump X <br /> 12 PLUS Turbine Sump X <br /> T3 SU Turbine Sump X <br /> UDC 1-2 X <br /> UDC 3-4 X <br /> UDC 5-6 X <br /> UDC 7-8 X <br /> Technician's Signature:Richard Cummings,Nick Patrick Date:7/31/02 <br /> SWRCB December 2001 <br />