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SWRCB,January 2002 0 Page a-of A3 <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 thisform to report resultsfor all components tested The completed form, written test procedures, and <br /> printouts ftom tests(iapplicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 4. FACILITY INFORMATION <br /> Facility Name: Flying J Date of Testing: 3/08/05&3/04/0-5 <br /> Facility Address: 1501 Jack Tone Road Ripon,C .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(iftresent during testing): <br /> 5. TESTING CONTRACTOR INFORMATION <br /> Company Name: Dialysis North <br /> Technician Conducting Test: Russell Rogers/Greg Hartman <br /> Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: License Number: 99-1292/03-1640 <br /> Manufacturer Training <br /> Manufacturer Com pnent(s) Date Training EK,�es <br /> -6. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC Sump# 1/2 X El El ❑ UDC Sump# 17/18 X 17 0 0 <br /> UDC Sump#3/4 X UDC Sump# 17 Satellite X <br /> UDC Sump#5/6 X El 11 E] UDC Sump# 18 Satellite X El D 0 <br /> UDC Sump#7/8 X 0- El El UM SUMP# 19 X Ll <br /> DC Sump#9/10 X El El E] UDC Sump# 19 Satellite X <br /> UDC Sump# 11/12 X 0 El E] UDC Sump#20 X <br /> UDC Sump# 13/14 El X El E] UDC Sump#20 Satellite X E! [I El <br /> UDC Sump# 13 Satellite X 0 0 E] UDC Sump#21 X- 0 El 0 <br /> UDC Sump# 14 Satellite X ❑ E] Ej UDC Sump#21 Satellite x El ❑ 0 <br /> T5-C-Sump# 15/16- --- -- X [I El ❑ UDC Sump#22 X 11 11 0 <br /> UDC Sump# 15 Satellite X UDC Sump#22 Satellite X P Ll 0 <br /> UDC Sump# 16 Satellite X t El ❑ 11 [--11 0 L9 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests <br /> Left sump test water in 55 gallon drums. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Zvltoe-vI64 Date:. - 5 -� 3-9-0,S <br />