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1 <br /> SWRCB,January 2002 Page of <br /> Page 1 of 3 0. <br /> Monitoring System Certification <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: Beacon Tesoro#67080 Date of Testing 11/29/02 <br /> Facility Address: 2448 W Kettleman Lodi Ca 95242 <br /> Facility Contact: Beth Portschelier Phone: 209-369-3124 <br /> Date Local Agency Was Notified of Testing:11/26/02 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Alpha Petroleum Services Inc <br /> Technician Conducting Test: Courtenay Jenvey <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:Contractor A Hazardous License Number:742 466 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Barett Engineering Model 300 hydrostatic sump tester 10/01/03 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Dispenser 7/8 X ❑ ❑ X ❑ ❑ ❑ ❑ <br /> Regular Unlead Sump X ❑ ❑ X ❑ ❑ ❑ ❑ <br /> Plus Sump X I ❑ ❑ X ❑ ❑ ❑ ❑ <br /> Supreme Sump X ❑ ❑ X ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 110 Gallons of sump water was left on site in DOT drums And Clearly Marked <br /> In an enclosed area <br />