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`tWRCB January,2002 Job#: 029132 Pae ofT� <br /> Secondary Containment Testing Report FormLL <br /> This form is intended.for r use by contractors performing periodic testing of UST secondary containment systems. Use 7 L00 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, an <br /> printouts,from tests(if applicable), should be provided to the facility owner/operator for submittal to the local`944% MAT HEALTH <br /> PE ICES <br /> Facility Name: Stockton, CA Switch Date of Testing: 10128/2005 <br /> Facility Address: 3807 Coronado Ave Stockton CA 95204 <br /> Facility Contact: Ron Williams Phone: 209-937-5800 <br /> Date Local Agency Was Notified of Testing: 10126/2005 <br /> Name of Local Agency Inspector(if present during testing) <br /> 2. TESTING CONTRA('TO R INFORMATION <br /> Company Name: Shirley Environmental Testing <br /> Technician Conducting Test: Robert Soto <br /> Credentials: p CSLB Licensed Contractor ® SWRCB Licemed Tank-Tester <br /> License Type: License plumber: <br /> Manufacturer Training <br /> Manufacturer component(s) Date Training Expires <br /> Incon TS-STS <br /> Pressure with a 4"gauge <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repaits Component Fast F,, Not Repair <br /> Tested Made Tested Made <br /> SL STP 10 ❑ 0 0 0 0 0 <br /> SL Fill Bucket 10 ❑ 0 0 ❑ 0 <br /> eturn Secondary H 10 11 1 11 0 11 IJ ❑ <br /> upply Secondary 0 10 <br /> ank Ann Wet <br /> If h-,-drostatic testing-was performed.describe what was done with the crater after completion of tests: <br /> Pui in 55 Galrums <br /> CERTIFICATION OF'TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of ny,knowledge,the facts stated in this documeid are accurate and in fill compliance with legal requirements <br /> Technician Name(print): Robert Soto <br /> Technician's Signature: Date: 10128/2005 <br /> i� <br />