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7SWRCB,January 2002 IE Page_Lof I
Secondary.Containment Testing Report Form
This form is intended for use by`contractorsperformmg periodic testing of UST secondary containment systems. Use:the
appropriate pages of this form to report results for.all components tested The completed form, wrimen test procedures, and
printouts from tests(if applicable),should.be provided to the facility aKwer/operator for submittal to the local regulatory agency.
1. -FACILITY INFORMATION .
Facility Name: MIKE'S FOOD&-LIQUOR Date of Testing: 12-10-10
Facility Address: 23.00 PANAMA.LANE BAKERSFIELD,CA
Facility Contact: MIKE Phone:
Date Local Agency Was Notified of Testing: 11-10-10
.Name of Local Agency Inspector(rf present-during testink): ERNIE MEDINA
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test:.. ' RICH PHU;LIPS .
Credentials: 0 CSLB Licensed Contractor. Q SWRCB Licensed Tank Tester
License Type: 'License Number
Manufacturer Training
Manufacturer Component(s)," . Date Training Expires
INCON 6-11-12
3. SUMMARY OF TEST RESULTS. ..
Not Repairs Not Repairs
Component Pass Fail Component Pan::Fail
Tested. Made Tested Made
DIESEL,SPILL BOX X p p
❑ ❑ ❑ ❑.
❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
❑ ❑ 0 ❑ ❑ ❑ ❑ ❑
Q ,o o: a o a ❑ ❑
❑ ❑ ❑ ❑ a a ❑ ❑
❑ ❑ ❑ . ❑ ❑ . ❑ ❑ ❑
a ❑ o' a ❑ ❑ ❑ ❑
❑ : ❑ ❑ ❑ ❑ ❑ a ❑
a o o n o ❑ ❑ o
CJ. ❑ ❑ D 0 F1 ❑
1f hydrostatic.testingwas performed,describe what Was.done with.the water after completion of tests:
RETEST AFTER NEW BUCKET WAS INSTALLED
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best.of my knowledge,the facts state is document are accurate and In fkU compliance with legal requirements
Technician's Signature: Date: 12-10.10
iiiiillllllllllllll 16
IE
7SWRCB,.January 2002 - Page4of 2..
9. StIL JOVER.)FIQ;L CONTAIlOIENT.BOXES
Facility is Not Equipped With Spill/Overfill.6otainment Boxes p
SpilUOverfiill iContainment Boxes:are Preset but were Not Tested p
Test Method Developed By: . 0-Spill:Bucket Manufacturer .. X"Industry" Standard ❑Professional Engineer
D Other(Specify)
Test Method"Used: ❑Pressure D Vacuum X.Hydrostatic
D Other(Specify) .
Test Equipment Used 1NCON Equipment.Resolution: -0,002
Spill Boa#DSL S pin Boa#DSI: Spill Box# Spill Box#
Bucket Diameter:: 12" 12"
Bucket Depth: 14" 14"
Wait time between applying
pressure/vacuum/water and I3 MIN IS MIN
starting test:
Test,Start Time 12'.21 12:42
Initial Reading%): 4:955 4.956
Test End Time: 12:38.. 12:57
Final Reading..(RF): 4:955 4:956
Test Duration: 1.5 MIN 15 MIN
Change.in Reading.(RF-R): 0 0
Pass/Fail Threshold or -0:002 -0:002
Criteria:
Comments— ('include r rmation on repairs made.prior to testing;and recommended f�IIow-up for japed'iests)
a
MIKES FOOD
2300 PANAMA LN
BAKERSFIELD CA
1- 80=584-6266
02/20/2002 12.38 AM
SUMP LEAK TEST REPORT
DSLF,iLB
TEST STARTED 12.23 AM
TEST STARTED 02/20/2802
BEGIN LEVEL 4.9558 IN
END TIME 12:38 AM
END DATE 82/20/2002
END LEVEL 4.9559 IN',
LEAK THRESHOLD 0.082. IN
TEST RESULT PASSED
MIKES FOOD
2390 PANAMA LN
BAKERSFIELD CA
1-8 -984--6266
02i20/2002 12:57 AN
SUMP LEAK TEST REPORT
DSLFILB
TEST STARTED 12:42 AN
TEST STARTED 02!20!2882
BEGIN LEVEL 4.9568 IN.
END TIME .1257:AM
ND
E DATE 02r2k1 02
END LEVEL 4,;9569 -IN
LEAK THRESHOLD . 0 882 ;IN
TEST RESULT' PASSED
�V1
SB989 TESTING Em., RE REPORT
SITE NAME:MIIKE'S FOOD.&LIOUOR DATE: 12-10-10
ADDRESS: 2300PANAMALANE CHNIC HII. IPS
C BAKERSFILED CA SIGMA
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE
TESTING.
REPAIR& lih
LABOR:
PARTS INSTALLED:
NAME. TITLE:
SIGNATURE'.,
THE_ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING
THE APPROPRIATE PARTY TO.HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMA,NTAL FOR,
ANY NEEDED RETESTING.THIS AI:SO RF EASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROMWON-COMPLIANCE.
A COPY OF THIS DOCUMENT HAS BEEN LEFT'ON=SITE FOR YOUR
CONVIENENCE.