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'SWRCB January,2002 � Page_of <br /> Secondar•Containment Testing Repor�'Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform 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. FACILTTY INFORMATION c-7 o 13 os r� <br /> Facility Name: USA Petroleum#065 Date of Testing 11/2512002 <br /> Facility Address: 2500 West Lodi Lodi CA 95242 <br /> Facility Contact: Phone: 208333-9834 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(iifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Shirley Environmental Testing <br /> Technician Conducting Test: Perry Ellis <br /> Credentials: Qx CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A HIC HAZ License Number. 81 S <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UNLREG Line Annular X x <br /> Retest <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFFIC IOF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> e <br /> To the best of my knowle ,the fa stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: /.�i>Jl �1 / Date: 11/25/2002 <br />