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Page 1 of 2 <br /> Elite IV Contractors <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 /> printoutsfrom tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: <br /> Facility Narn- Vanco Truck and Auto-Plaza <br /> Facility Address: 1033 W Charter Way Stockton Ca 95206 <br /> Phone:916-369-1665 <br /> Facility Contact: Mike opan <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> TA0249501 <br /> Z, TESTING CONTRACTOR INFORMATION <br /> Company Name : Elite IV Contractors <br /> Technician Conducting Test:Joe Bartholdi <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type; A-HAZ License Number: 1001331 <br /> Manufacturer Trainin Date Training Ex ices <br /> Manufacturer Component(s) <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Not Repairs Component Pass Fall Tested Made <br /> Component Pass Pail Tested Made <br /> #819 X <br /> #9110 x <br /> #11112 X <br /> #14 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CER'T'IFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated i this doc meni are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br /> i <br />