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S W RCB,January 2002 Page of Secondary Containment Testing Report Form 'Phis form is intended�r,uspjV 2ctors performing periodic testing of UST secondary containment systems. Use the appropria form to report results for all components tested The completed form, written res, and printoutsfrom tests(if applt�gbl #1FaYuld be provided to the facility owner/operator for submittal to the Ioc��lf SAN, FY I±d U S T t'L TI. FACILITY INFORMATION S '; ::)�1 2 Facility Na*Mlt: J&L MarketI Date of Testing: HE Xtv T 5 "r rAl Facility Address: 8115 S. El Dorado Street,French Camp Ca 95321 r A H r�1El,f T Facility Contact: Jim Phone: 209-982-0912 Date Local Agency Was Notified of Testing: 8/25/05 Name of Local Agency Inspector('(present during testing): None Present 2. TESTING CONTRACTOR INFORMATION SEP _ Company Name: JP Petroleum Service Technician Conducting Test: John Puumala ENVIRONPILN I HLALTH Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester ` ' -S License Type: A License Number: 811471 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Pipe Sump 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Pipe Sump 2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Pipe Sump 3 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line 2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line 3 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 1&2 x ❑ ❑ x ❑ ❑ ❑ ❑ UDC 3&4 x ❑ ❑ x ❑ ❑ ❑ ❑ UDC 5&6 x ❑ ❑ x ❑ ❑ ❑ ❑ UDC 7&8 x ❑ ❑ x ❑ ❑ ❑ ❑ Annular 1 (Diesel/Premium) x ❑ ❑ ❑ ❑ ❑ ED 11Annular 2 (Regular) x L1 El 11 ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water was filtered and pumped back to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signa _- Date: