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Dec 31 02 11:02a Fra n Hill TT`0 ' F. 6 SWRCB, January 2002 Page of 7 �UHUt'UiS� GOA g Secondary Containment Testing This form is intendedfor use b>> contractors performing periodic testing of USTsecondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Food 4 Less I Date of Testing: 12/12/02 Facility Address: 3434 Manthey Rd Stockton WO# 111063 1:30 PM Facility Contact: Gary Pforr Phone: 925-674-6707 Date Local Agency Was Notified of Testing : 12/10/02 Name of Local Agency Inspector (tf present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Franzen -Hill Corp 1100 North J Street Tulare, CA 93274 Pass Technician Conducting Test: Felix Mendes Not Tested Repairs Made Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester Not Tested License Type: A,B,C-61/D40 HAZ License Number: 304147 Manufacturer Manufacturer Training Component(s) Date Training Ex fres Environ Piping and Testing 10/03 Total Containment Piping and Testing 10/03 Incon Testing 09/04 Cadwell Testing 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: 3�C��,<l s P7f-1- u.1 St fe- Czt6 ei L% 11 it k,.L 4n J c/i,-y o5e 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 Signature: /�``' ' Date: 1.7- - /Z - G ")-. Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made ❑ ❑ ❑ ❑ ❑ ❑ ❑ c,:, I,r v ❑ El D El El❑ CG-1cc.r J� ►+%i ❑ ❑ ❑ ❑ ❑ ❑ ❑ L4r-% #1 ❑ ❑ ❑ ❑ ❑ 0 SDG i- 0 ❑ ❑ ❑ ❑ ❑ ❑ U -k ❑ ❑ 0 E ❑ 0 ❑ L 1� ❑ 0 0 ❑ ❑ ❑ ❑ UDC, 7-5 ❑ 0 ❑ 0 ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ C I ❑ C 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: 3�C��,<l s P7f-1- u.1 St fe- Czt6 ei L% 11 it k,.L 4n J c/i,-y o5e 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 Signature: /�``' ' Date: 1.7- - /Z - G ")-.