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�;WRCB, January 2002 0 � page_l of 2 <br /> Secondary Containment Test Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> W,'propriate pages of this form-to report results all-components-tested.—The-completed=form,:written test procedures;and <br /> ntoufs 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: Stockton, CA Switch Date of Testing: 11-15-2006 <br /> Facility Address: 3807 Coronado Ave Stockton CA 95204 <br /> Facility Contact: Pay Lemes Phone: 909476-7443 <br /> Date Local Agency Was Notified of Testing: 1116/2006 <br /> Name of Local Agency inspector(if present during testing) none present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Shirley Environmental Corporation <br /> Technician Conducting Test: Paul Magana <br /> Credentials: O CSL B Licensed Contractor O SWRCB Licensed Tank Tester <br /> License Type: General A-HAZ ILicense Number: 769519 <br /> Manufacturer Training_ <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pas Fail Tested Made Component Pas Fail Tested Made <br /> Diesel bucMO <br /> ❑ El El 11 D_ <br /> ❑ ❑ 1:1 ❑ ❑ ❑ 1:1E] El El❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ fl ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> .......................I.......,...................................................... <br /> hO.flr.stin..S.iter................................. .....................................................................................................................................................••••.........................._.............. <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 /> X� Date: 11-15-2006 <br /> Technician's Signature: <br />