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SWRCB,fanuary 2002 " Page I of a <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 thisforin 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 ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Country Market Place Date of Testing: 47-04 <br /> Facility Address: 1789 W.Charter Way,Stockton,CA 95206 <br /> Facility Contact: Pat Phone: 209-870-3508 <br /> Date Local Agency Was Notified of Testing:46-04 <br /> Name of Local Agency Inspector(r(present during testing): APR 1 2 2004 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Dialysis North PERMITISERVICES <br /> Technician Conducting Test: Greg Hartman <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: License Number: 03-1640 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not RepairsComponentPave Fall Not Repairs <br /> Torted Made Tested Made <br /> Tank# 1 —87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ FE, TEi <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water ager completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In Akis document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 4 ", ' y <br />