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Page / of <br /> SWRM,.lanuary 2002 <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor 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 proce�est cy <br /> printoutsfrom tests(if applicable), should be provided to the facility owner/operatorfor submittal to the Iota!re ato agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ' ;$ ' V O Date of Testing: ott& <br /> Facility Address: G 4,jCte"RL/—/4-- 2AG 9S <br /> Facility Contact: Phone: ? <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Fueling&Service Technologies,Inc.(FASTECE) <br /> Technician Conducting Test: SRiE PZAFn/Gi4 <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,EAZ,C21 License Number. 794519 <br /> Manufacturer Training <br /> Manufacturer Com ones s Date Training Expires <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> e�°7 au, vcf 2 / JA El 11 11eva rL <br /> ❑ ❑ ❑ F11,4- SvXllo 9 ❑ ❑ ❑ <br /> G .o R 1 ❑ ❑ ❑ le ❑ ❑ ❑ <br /> '�T 7ViZ / SL- r ❑ ❑ ❑ 9 T7 /• ❑ ❑ ❑ <br /> ❑ ❑ ❑ 19171 `' s ❑ ❑ ❑ <br /> /-Z A ❑ ❑ ❑ i .R ❑ ❑ ❑ <br /> 3- e/ !9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9V ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ I ❑ ❑ ❑ <br /> L e 9-/o ❑ ❑r� ❑ ❑ ❑ ❑ JE]Ci —/2 El❑ J& ❑ ❑ ❑ ❑F/c L Sz1^n❑ El El El ❑ ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after co <br /> See attached testing procedures. SB 969 3-Year Compliance Testing <br /> WO#060310-045 <br /> COSTCO#29978?js-df - <br /> 3250 W Grant Line/Hwy 205 _ <br /> Tracy,CA 95304 <br /> CERTIFICATION OF TECENICIAN RESPONSIBLE FOR CONLua.iuN%, irub izt uN" <br /> To the best of my knowledge,the facts stated In Bels document are accurate and in full compliance with legal requirements <br /> Date: e�q- — / O <br /> Technician's Signature: Ciod�t� ��L�ieC.ig � - <br />