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S WRCB,January 2002 Page i of L <br /> Secondary Containment Testing Report Form <br /> This 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 /> prinloutsfrom tests(iifap ARCO/BP - 04932 loperarorfor submittal to the local regulatory agency. <br /> 16 E HARDING WAY )N <br /> Facility Name: STOCKTON, CA 95204 Date of Testing: <br /> Facility Address: NO SB989 TESTING <br /> Facility Contact JA Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(6(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: j:-�_ r_v -� . /N C <br /> Technician Conducting Test <br /> t�redentiaLs: CSLB Licensed Contractor O SWRCB Licensed Tank Tester <br /> License Type: ' C(D I b' D OA License Number. pp� <br /> Manufacturer Training <br /> Manufacturer Co s Date Trainin ices . <br /> 3. SUMMARY OF TEST RESULTS <br /> Component PassFaii Tested �irs d Component Pass Fal TNest�ed JMdeM ❑ ❑ 0 <br /> 9 0 ❑ <br /> El <br /> ❑ ❑ ❑ <br /> t yI :, 01 ❑ ❑ ❑ 10 0 ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ 10 a 1 ❑ <br /> ❑ 01 0 1 ❑ ❑ 10 ❑ 1 0 <br /> ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 101 0 1 ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ 1111 0 0 <br /> 0 0 ❑ ❑ ❑ 101 ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ El a <br /> ❑ ❑ ❑ ❑ 11 El El 11 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECEMCLkN RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the best of my knowledge,the facts stated m this document are aeeuratc and in full compliance with legal requirements <br /> Technician's Signature: Date: 14? 2 z -z..y <br />