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Page 1 of 7 <br /> Secondary Containment Testing Report Form <br /> Thu form is intended for use by contractors performing periodic testing of UST secondary containment systems. Usethe <br /> appropriate pages of this form to report results for all components tested. The completedform, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator far.submittal to the local regulatory agency. <br /> 1. FACQdTV INFORMATION <br /> Facility Name: Rancho San Miguel Date of Testing: March 23,20M <br /> Facility Address: 610 South Cherokee Lane Lodi,Ca. WO#03-11109 Time: 8:00 am <br /> Facility Contact: Gilbert Silva Phone: (209)944-4577 <br /> Date Local Agency Was Notified of Testing: March 16.2006 <br /> Name of Local.Agency inspector(ifprecent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Franzen-Hill Corp 1100 North J Street Tulare.CA 93274 <br /> Technician Conducting Test: John Ellis <br /> Credentials: x CSLB Licensed Contractor - 111 SWRCB Licensed Tank Tester <br /> License Type: A,B,C-61ID40 HAZ License Number: 304147 <br /> i <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Environ Piping and Testing 12/07 <br /> Total Containment Piping.and TeLfipg 9/07 <br /> bacon Testin 11/07 <br /> Cadwell Testing <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC !2 X X <br /> UDC34 X X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water returned to the test trailer storage taink. <br /> CERTIFICATION OF TECHNICIAN RESPONSTRLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the farts stated in this document are accurate and in full compliance with legal requirements <br /> Technician'sSignatur Date: 7 ,)�� <br />