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I <br /> SWRCB,January 2002 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, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ramos Oil Company–French Camp Date of Testing: 12-16-14 <br /> Facility Address: 10855 S.Harlan Road, French Camp Ca 95231 <br /> Facility Contact: Steve Richardson Phone: 916-371-2570Dr7nf—I'l 1r—E% <br /> Date Local Agency Was Notified of Testing: 12/11/14 <br /> Name of Local Agency Inspector(fpresent during testing): PEE 24 281-If <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service �L�PE-RMrMtHvluHEALTH <br /> .5 <br /> Technician Conducting Test: Gabe Garcia <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5281582 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Line 1 x ❑ ❑ ❑ Sump 1 x ❑ ❑ ❑ <br /> Line 2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 3 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 4 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 5 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line b x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1A x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1-2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 2A-3A x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3-4 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 4A-5A x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5 x ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:-12/16/14 <br />