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• • • 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 (f applicable), should be provided to the facility owner/operator for submittal to the local <br /> regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: 8/01/02 <br /> Facility Beacon#3492 <br /> Facility Address:470 North Main Manteca,CA 95336 <br /> Facility Contact:Manager Phone(209)823-1344 <br /> Date Local Agency Was Notified of Testing: 7/29/02 <br /> Name of Local Agency Inspector Present:None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> rTechnician <br /> e: Bonsall Petroleum <br /> ducting Test: Richard Cummings,Nick PatrickX CSLB Licensed ContractorSWRCB Licensed Tank Tester <br /> nd #: A,B,HAZ #682742Training by Manufacturerturer Com onent s Date Trainin Ex fres <br /> ST2000P 12/03 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: 2 Number of Pi-ing Runs Tested: 2 <br /> Number of Submersible Pump Sumps Tested: 2 Number of UDC Boxes Tested: 4 <br /> Number of Fill Sumps Tested:0 Number of Overfill Boxes Tested. 0 <br /> Component PasFail Comments <br /> Pas., <br /> Tl RU Annular X <br /> T2 SUAnnular X <br /> Ll RU Containment Line X <br /> L2 SU Containment Line X <br /> Tl RU Turbine Sump X <br /> T2 SU Turbine Sjunp X <br /> UDC 1-2 X <br /> UDC 3-4 X <br /> UDC 5-6 X <br /> UDC 7-8 X <br /> Technician's Signature: Richard Cummings,Nick Patrick <br /> Date: 8/01/02 <br /> December 2001 <br /> SWRCB <br />