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SWRCB,January 2002 Page 1 of 5 <br /> Petrotek Secondary Containment Testing AWED <br /> Verizon — Manteca - 2006q <br /> This form is for use by contractors performing testing of UST secondary containment systems. Use this form to report all c dnpeifls tA06 <br /> The form,written test procedures,and printouts,should be provided to the facility operator for submittal to the loca e Into aIV94f HEALTH <br /> 1. FACILITY INFORMATION PERMIT/SERACES <br /> Facility Name: Verizon I Date of Testing: 9/5 & 14/2006 <br /> Facility Address: 2551 East Louise Avenue, Manteca, CA <br /> Facility Contact: D) I Phone: 510-377-2118 <br /> Date Local Agency Was Notified of Test: 8/31/2006 the San Joaquin Environ Health Dept was notified <br /> Name of Local Agency Inspector: Muniappa Naidu ❑x was ❑was not present <br /> 2. TESTING CONTRACTOR INFORMATION_ <br /> Company Name: Petrotek, 925 Commercial Street, San Jose, CA 95112 --- 408-453-1888 <br /> Technician Conducting Test: Jim Keltner <br /> Credentials: CSLB Licensed Contractor License Type: A, B, C61-D40, Haz Mat License #590295 <br /> Manufacturer Trainin <br /> Intelligent Controls INCON ST-STS-3K <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comments <br /> Tested Made <br /> Annular Space ® ❑ ❑ ❑ Tested 9/14/06 <br /> Primary Supply Piping ® ❑ ❑ ❑ Tested 9/5/06 <br /> Primary Return Piping ® ❑ ❑ ❑ Tested 9/5/06 <br /> Primary Vent Piping ® ❑ ❑ ❑ Tested 9/5/06 <br /> Secondary Supply Piping ® ❑ ❑ ❑ Tested 9/5/06 <br /> Secondary Return Piping ® ❑ ❑ ❑ Tested 9/5/06 <br /> Secondary Vent Piping ® ❑ ❑ 0 Tested 9/5/06 <br /> Turbine Sump ® ❑ ❑ ❑ Tested 9/5/06 <br /> Transition Sump ® ❑ El ❑ Tested 9/5/06 <br /> Spill Bucket ® ❑ ❑ ❑ Tested 9/5/06 <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Test Medium [Water] was filtered through an activated charcoal filter and reused <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, facts stated are accurate and in compliance with legal requirements <br /> Technician's Signat re:~ Date: 9/14/2006 <br />