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SW RQB, January 2002 <br />Secondary Containment Test ReportForm <br />Page 1 of 3 <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 to UN i the local regulatory agency. <br />1. FACILITY INFORMATIO Uci PM 9: na <br />Facility Name: Yellow Transportation TCY jDate of Testing: 5-23-2007 <br />Facility Address: 1535 E. Pescadero Ave. Tracy CA 95376 <br />Facility Contact: <br />IChris Roy <br />Phone: <br />209-833-1300 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing) <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Shirley Environmental Testing <br />Technician Conducting Test: Edwin Coreas <br />Credentials: O CSLB Licensed Contractor O SWRCB Licensed Tank Tester <br />License Type: <br />License Number: 031652 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Wllater..was..l!~tt.a0.sit�.l szr.AxaA.e[_diaposal........................................................................................................................................................................ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: l Date: 5-23-2007 <br />Uo00 <br />0000 <br />Wo00 <br />0000 <br />WQQQ <br />oo00 <br />Wo00 <br />0000 <br />- <br />o00 <br />0000 <br />.. .. <br />o000 <br />0000 <br />- <br />o00 <br />0000. <br />0000 <br />0000 <br />v000 <br />0000 <br />mom" <br />0o00 <br />0o00 <br />0000 <br />0o00 <br />0o00 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Wllater..was..l!~tt.a0.sit�.l szr.AxaA.e[_diaposal........................................................................................................................................................................ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: l Date: 5-23-2007 <br />