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09/22/2010 10:28 209-465-4988 HMC HENDERSON MAIN PAGE 05111 <br /> SWRCB,January 2002 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, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TEXACO I Date of Testing: 6-22-10 <br /> Facility Address: 1405 CALIFORNIA ST,ESCALON,CA 95320 <br /> Facility Contact: CHOCO I Phone: 209-838-7674 <br /> Date Local Agency Was Isotified of Testing: 6-17-10 <br /> Name of Local Agency Inspector(fpresent during testing): Twee <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CS U- Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: Service Technician License Number. 04-1677 <br /> Manufacturer Trainint* <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 2-28-2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 SPILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 SPILL BUCKET X U U U U U U U <br /> DSL SPILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Q ❑ Q Q ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 11 ❑ Q <br /> El ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ Q ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe who was done with the water after completion of tests: <br /> Left on site <br /> CERTIFICATION OF TECIINI RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts Sta this do c t are accurate and in full compliance with legalre utrements <br /> Technician's Signature: Date: <br />