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2560 Soquel Avenue Ste 202 <br /> Santa Cruz CA 95062 <br /> T: 831.475.8141 <br /> F: 831.475.8249 • <br /> 116 <br /> CA Lic#693807 A-HAZ B-mc OEM 01 <br /> Secondary Containment Testing Report Form <br /> 1. Facility Information <br /> rNsme <br /> Name: Corner Store 3698 Date of Testing: 7101/2014 <br /> Address: 153 E. 11th Street,Tracy,CA 95376 <br /> Facility Contact: <br /> Phone: 208-328-8815 <br /> ocal Agency Was Notified of Testingof Local Agency Inspector(ifpresent during testing): <br /> 2. Testing Contractor Information <br /> Company Name: Triton Construction. 831-475-8141 ext.205 <br /> Technician Conducting Test: James Bohner <br /> License Information: California Contractor's State License Board CSLB #693807 A HAZ B ASB <br /> Manufacturer Certifications <br /> ICC Certification#8205858 Expiration Date:7/09!2015 <br /> INCONI TS-STS Certification#174953705 Expiration Date 8/15/2015 <br /> 3. Summary of Test Results <br /> Is this a retest of previously failed components? ❑YES <br /> Compone P F NT RM Component P F NT RM <br /> Annulars(All) © El El ElEl ❑ ❑ Li <br /> Secondary Sumps(All) © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Piping (All) ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ - <br /> ❑ ❑ ❑ <br /> UDCs(All) © ❑ ❑ ❑ ❑ <br /> Fill Sumps(All) ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Buckets(All) © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> -- ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> CERTIFICATION OF TECHNICLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledthege, facts stated i is docur ent a accurate and in full compliance with legal requirements <br /> Technician's Signature: Dae: 07/01/2014 <br /> Technician's Name: Ja es hnet <br />