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2560 Soquel Avenue Ste 202 I T P <br /> Santa Cruz CA 95062 1 <br /> T:831.475.8141 <br /> F:831.475.8249 <br /> CA Lic#693807 A-HAZ 13-HIC <br /> Secondary Containment Testing Report Form <br /> 1. Facility Information <br /> Facility Name: Valero 3698 Date of Testing: 07/1112013 <br /> Facility Address: 153 East 11th St.Tracy,CA 95376 <br /> Facility Contact: Phone: 209-832.8815 <br /> Date Local Agency Was Notified of Testing: 0612712013 <br /> ;Name of Local Agency Inspector(if present during testing): Thuy Tran <br /> 2. Testing Contractor Information <br /> Manufacturer Component Expiration Date �. <br /> INCON TS-STS 12112@014 <br /> 3. Summary of Test Results <br /> Is this a retest of previously failed components? YES <br /> Component P F NT RM - Component P j F NT RM <br /> �- — ---------- - -- .. , ..0.. ❑ <br /> Spill Buckets:All ® ❑ ❑ El El ❑ <br /> ❑ ❑E3 D 0 El❑ ❑ <br /> - -- - o ElEl ❑ <br /> --O . O 0 0 <br /> ❑ ❑ ❑ 0 0 0 0 0 <br /> _ o ❑ ❑ ❑ El 0 11 El <br /> ❑ ❑ ❑ ❑ 0 a 0 0 <br /> CERTIFICATION—OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my know;nOcker <br /> is stated—' is d ument are accurate and in full compliance with legal requirements <br /> Technician's Signature Date: 07/1112013 <br /> Technician's Name' J <br /> 1of2 <br />