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SWRCB,Janumy 2002 0 Page L of a <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST second containment systems. (Ise the <br /> appropriate pages of this form to report results for all components tested. The completed four:, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 7. FACILITY INFORMATION <br /> Facility Name: Flying J ==Date of Testing: 3/08/05&3/09/05 <br /> Facility Address: 1501 Jack Tone Road Ripon,CA.95366 <br /> Facility Contact: Rick Callahan or RicardoPhone: 209-5994141 <br /> Date Local Agency Was Notified of Testing: 2/23/05 <br /> Name of Local Agency Inspector(if present during testing): <br /> 8. 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: I License Number: 99-1292/03-1640 <br /> ManufactureE Training <br /> Manufacturer Com onent(s) Date Training EmiTs_ <br /> 9. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested —Made Tested Made <br /> UDC Sump#23 X o o ❑ UDC Sump#29 X ri o D <br /> UDC Sump#23 Satellite X El El E] UDC Sump#29 Satellite X LJ D 0 <br /> UDC Sump#24 X E] E] ❑ UDC Sump#30 X <br /> DC Sump#24 Satellite E] X L] ❑ UDC Sump#30 Satellite X <br /> TW_Sump#25 X 0 0 El [1 0 El D <br /> UDC Sump#25 Satellite X El D 11 0 0 0 0 <br /> UDC Sump#26 X 0 D 0 0 <br /> UDC Sump#26 Satellite X D El 0 0 0 11 D <br /> UDC Sump#27 X 0 0 0 0 Li r] 0 <br /> UDC Sump#27 Satellite X 0 1 0 B_ D D- D El <br /> UDC Sump#28 X 0 E] 0 0 EJ 0 El <br /> UDC Sump#28 Satellite X El , El El D D El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests <br /> Lefts test water in 55 gallon drums. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowled e, efacts stated in this document are accurate and infiff compliance with legal requirements <br /> Technician's Signature: Date:3-6- cs _.. 3-9_c,_s <br />