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r <br /> SWRCB,January 2002 <br /> ?�Co) aP 2 <br /> Secondary Containment ��y7r\ <br /> �"Y ent Testing Report Form <br /> � t� <br /> MAY 0 5 2003 <br /> This form is intended far use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable <br /> the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lathrop Chevron <br /> Dade cf Testing: 429-03 <br /> Facility Address: 140 E Lathrop, Lathrop, Ca.95330 <br /> Facility Contact: Bob Phone. (209}982-5779 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(it present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC Services <br /> Technician Conducting Test:Michael Mullaly <br /> Credentials:CSLB Licensed Contractor <br /> License Type:AIHaz License Number:779287 <br /> Manufacturer Training <br /> .Manufacturer Components} <br /> Incon Date Training Expires <br /> TS-STS 1/22/2005 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Component Pass Faif Tested Made <br /> Not Repairs <br /> Component Pass Fail Tested Made <br /> UDC Disp.7-8{RETEST) ,f ❑ Q ❑ <br /> UDC Disp.11_12(RETEST) ❑ ❑ Q 11i ll ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water is returned back into test tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TEST <br /> To the best of my knowledge,the facts stated in this <br /> do c i t re accurate a7dinillcompliance with legal requirements <br /> Technician's Signature: /J <br /> Date: `z <br />