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SWRCB, January 2002 Page 1. <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 (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: H& M (BOYETT PETROLEUM) <br />Date of Testing: 07/28/2006 <br />Facility Address: 2501 E JACKSON AVE ESCALON, CA, 95320 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 838-3971 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />RAYMOND SIMMS <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />EJSWRCB Licensed Tank Tester <br />Mm <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />■� <br />W <br />� <br />Spill Box dslM= <br />3. SUMMARY OF TEST RESULTS <br />- <br />Component <br />If <br />Spill Box 87 11- <br />Mm <br />■� <br />W <br />� <br />Spill Box dslM= <br />�000 <br />ao�o <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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: 07/28/2006 <br />