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0 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, <br /> and printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local <br /> regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Beacon#3698 1 Date of Testing: 8/05/02 <br /> Facility Address: 153 East I I"Street Tracy,CA 95376 <br /> Facility Contact:Manager Leta Nelson Phone(209)832-8815 <br /> Date Local Agency Was Notified of Testing: 7/26/02 <br /> Name of Local Agency Inspector Present:None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Bonsall Petroleum <br /> Technician Conducting Test: Richard Cummings,Nick Patrick <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type and#: A,B,HAZ #682742 <br /> Training by Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> USTest UST2000P 12/03 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: 3 Number of Piping Runs Tested: 3 <br /> Number of Submersible Pump Sums Tested: 3 Number of UDC Boxes Tested: 3 <br /> Number of Fill Sumps Tested:0 Number of Overfill Boxes Tested: 0 <br /> ...................... . <br /> Component Pass Fail Comments <br /> Tl RU Annular X <br /> T2 RU Annular X <br /> T3 SU Annular X <br /> Ll RU Slave Containment Line X <br /> L2 RU Containment Line X <br /> L3 SU Containment Line X <br /> Tl RU S1aveTurbine Sump X Slave - Two SSI Boots installed <br /> T2 RU Turbine Sump X <br /> T3 SU Turbine Sump X <br /> UDC 1-2 X <br /> UDC 3-4 X <br /> UDC 5-6 X <br /> Technician's Signature: Richard Cummings,Nick Patrick Date: 8/05/02 <br /> SWRCB December 2001 <br />