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SWRCB,January 2002 10 7,:z,--Mage I of a?) <br /> Secondary Containment Testing ReporMravoo§ <br /> This form is intendedfor use by contractors performing periodic testing of USTsecon(bWffl@*RRy Use the <br /> appropriate pages of this form to report results for all components tested The complete Pedures, and <br /> i <br /> printouts from tests(if applicable), should be provided to the facility ownerl'operatorfor sub m' a to Al regulatory agency, <br /> I. FACILITY INFORMATION <br /> Facility Name: Flying J Date if Testing: 3/08/0-5 —3/09/05 <br /> Facility Address: 1501 Jack Tone Road Ripon,CA.95366 <br /> Facility Contact: Rick Callahan or Ricardo Phone* 209-5994141 <br /> Date Local Agency Was Notified of Testing: 2/23/05 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Dialysis North <br /> Technician Conducting Test: Russell Rogers/Greg Hartman <br /> Credentials: 11 CSL I3 Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: License Number: 99-1292/03-1640 <br /> manufacturer IEdighg <br /> Manufacturer Component(s) Date Traia�fires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pan Fail riot apairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Piping run#8—91 X 0 0 E] Piping sump#2—Diesel ❑ X <br /> Piping roan#7-89 X El El 0 Piping sump# 1—Diesel X F] [I [I <br /> Piping run#6—87 X I Spill box#9-91 X <br /> Piping run#5—Diesel X ❑ E] E] Spill box#8--91V/R X U El 0 <br /> Piping run#4—Diesel Siphon X El El L] Spill box#7—89 X ri o 0 <br /> Piping run#3—Diesel X El El E] Spill box#6—89 VIR X 0 El 0 <br /> Piping run#2—Diesel Siphon X E] E] Ej Spill box#5—87 <br /> Piping tun# I —Diesel X ❑ E] ❑ Spill box#4—87 V/R X 0 El 0 <br /> Piping sump#6—91 11 X El Ej Spill box#3—Diesel X 0 Li 0 <br /> Piping sump#5--89 El X El E] Spill box#2—Diesel F5 5- Ej <br /> Pipings #4—87 X El El E] Spill box# I —Diesel X 11 11 El <br /> Piping sump#3-Diesel El 11 El F1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests <br /> Leftsump test water in 55 gallon drums. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the best of my knowledge,thefacts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature- AA Date: 3-3 -oS -4 3-1 -q5 <br /> 7 <br />