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1 0 06ciiiVED <br /> SVV'RC13,January 2002 0 JAN082013 Page—of <br /> Secondary Containment TestingQ,*T,Wyn"..I I FA L" <br /> This form is intended for use by contractors performing periodic testing of UST secondary containnWwms. Use the <br /> appropriate pages ofthis 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ramos Oil Company–French Camp Date of Testing: 12-15-17 <br /> Facility Address: 10842 S.Harlan Road,French Camp Ca 95231 <br /> Facility Contact: Steve Richardson Phone: 916-371-2570 <br /> Date Local Agency Was Notified of Testing: 12/1/17 <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: Gabe Garcia <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC 9 5281582 <br /> mmmmmmmm <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail <br /> Tested Made Tested Made <br /> Line I x 0 El El SUMP I x 0 0 El <br /> Line 2 x 0 0 0 0 0 0 El <br /> Line 3 x 0 0 0 0 0 0 0 <br /> Line 4 x 0 0 0 El 0 El 11 <br /> Line 5 x 0 0 0 0 0 0 0 <br /> Line 6 x 0 El 0 0 El El 0 <br /> UDC 1A x 0 El 0 0 0 0 0 <br /> UDC 1-2 x 0 0 0 0 0 0 0 <br /> UDC 2A-3A x 0 0 El 0 0 0 El <br /> UDC 3-4 x 0 0 0 0 El 0 0 <br /> UDC 4A-5A x 0 El El 0 0 11 El <br /> UDC 5 x El El 0 El [I L <br /> If hydrostatic testing was performed,describe what was done with the Water after completion of tests: <br /> Water was filtered and re ed 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 infull compliance with legal requirements <br /> Technician's Signature: Aoo� Date: <br />