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SWRCB, January 2002 REG <br />OVED <br />Secondary Containment Testing Report Form JAN 2 4 2011 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of thisform to report results for all components tested The completedform, written It% �nd <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the loc :TH <br />1. FACILITY INFORMATION ��rrcGEE�; <br />Facility Name: A -ONE GAS N FOOD I Date of Testing: 12-17-2010 <br />Facility Address: 574 W. Grant Line Rd. Tracy, Ca. 95376 <br />Facility Contact: Ramesh Sood Phone: 209-523-6324 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): Thuy Tran <br />2. TESTING CONTRACTOR WFnRMATTraN <br />Company Name: Reliable Petroleum Services, Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A <br />License Number: 883706 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Fail <br />Not <br />Tested <br />3. SUMMARY OF TEST RES1T1.T1,q <br />Component <br />P <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Com <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 Annular <br />x <br />❑ <br />11 <br />11 <br />❑ <br />0 <br />0 <br />91 Annular <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />0 <br />❑ <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: �Y Date: 12-17-201 <br />