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1 <br />SWRCB, January 2002 %W 1%0( Page of <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 />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 />r <br />b. <br />6 <br />Facility Name: YELLOW ROADWAY CORPORATION -TRACY Date of Testing: 11/22+23/2004 <br />Facility Address: 1535 E. PESCADERO AVE. TRACY, CA. 93504 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing : 11/19/04 <br />Name of Local Agency Inspector (ifpresent during testing): MICHELLE LE, R.E.H.S. <br />2. TESTING CONTRACTOR MFCIRMATInN <br />Company Name: PROFESSIONAL SERVICE INDUSRIES <br />Technician Conducting Test: MICHAEL SILLS <br />Credentials: X CSLB Licensed Contractor S WRCB Licensed Tank Tester <br />License Type: A, C57 <br />License Number: 716703 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />24 HOUR LAKE TEST PERFORMED <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER TRANSFERRED TO AN ON-SITE OILIWATER SEPERATOR FOR <br />PROCESSING AND DISPOSAL. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, theeffaaaccts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: l�L�"/ / / �, Date: ll — —2 6 — G <br />=Wrrm <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER TRANSFERRED TO AN ON-SITE OILIWATER SEPERATOR FOR <br />PROCESSING AND DISPOSAL. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, theeffaaaccts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: l�L�"/ / / �, Date: ll — —2 6 — G <br />