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SWRCB, January 2002 • 0 Page _1_ of _7_ <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: BOYETT PETROLEUM #98 - H & M MARKET Date of Testing: JUN 9, 2008 <br />Facility Address: 2501 E. JACKSON AVE, ESCALON, CA 95320 <br />Facility Contact: ROHDA HENRY I Phone: (209) 549-5612 <br />Date Local Agency Was Notified of Testing: MAY 16, 2008 <br />Name of Local Agency Inspector (fpresent during testing): NONE PRESENT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A I License Number: 06-1672 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN 1/26/2009 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />87 PRODUCT LINE <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />87 STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 & DIESEL TANK ANNULAR <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />j ❑ <br />❑ <br />❑ <br />91 PRODUCT LINE <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />DIESEL PRODUCT LINE <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />DIESEL STP SUMP <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC#1-2 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC# 3 - 4 <br />❑ <br />® <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: JUN 9, 2008 <br />