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SWRCB,January 2002 Page [ of�� <br /> Secondary Containment Testing Report Form <br /> Yhis form is intended for 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 procedures, and <br /> printouts 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: S6 989 6 mo. test Date of Testing: c9 9 3— <br /> or <br /> Facility Address: WO#: 040920-117 <br /> Facility Contact: Costco#38 Phone: <br /> 1616 E. Hammer Lane & "Jest <br /> Date Local Agency A Stockton, CA 95210 <br /> Name of Local Agenc, <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Fueling&Service Technologies,Inc.(FASTECH) <br /> Technician Conducting Test: ,J p),p /J. . i L` *r-M C t <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,HAZ,C21 License Number: 794519 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> $7 7%c '.w = wrT ❑ ❑ ❑ / SFcv,,.JAA Y 4 N, ❑ ❑ ❑ <br /> ❑ ❑ ❑ .4. ,�, lL ❑ ❑ ❑ <br /> 871 Xj'at ✓,* ❑ ❑ ❑ 1'F-0v,G ❑ ❑ ❑ <br /> $72 tt , ❑ ❑ ❑ t C ❑ ❑ ❑ <br /> ito, ,ti Sz ❑ ❑ ❑ 3• N v)c ❑ 1 ❑ ❑ <br /> 41.1 vclre+^s X . ❑ ❑ ❑ s-G u c ❑ ❑ ❑ <br /> 972 SO ❑ ❑ ❑ `7- 6 U , ❑ ❑ ❑ <br /> 4 i k ti El ❑ 1-10 c ❑ ❑ ❑ <br /> ❑ ❑ ❑ lI-12 ❑ ❑ ❑ <br /> � 2 K k ❑ ❑ ❑ g7 72 �` �/I'hr✓ ❑ ❑ ❑ <br /> •� K �( ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 , SFc✓a R Lta" k ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> See attached testing procedures. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts st in this document are accurate and in full compliance with legal requirements <br /> F <br /> Technician's Signature: Date: 0 <br />