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POC <br /> moll 01SWIXISAFF <br /> Page 1 of 8 <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 appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if applicable),should <br /> be provided to the facility ownedoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quickie Kleen Date of Testing: 12/16/2009 <br /> Facility Address: 707 E Yosemite Ave Manteca, CA 95336 <br /> Facility Contact: Francene Escobar Phone: 209-814-6274 <br /> Date Local Agency Was Notified of Testing: 12/09/2009 <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 21 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number:880430 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> Caldwell N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87-1 Sum o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87-2 Sum old 91 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 / 8UDC © ❑ ❑ ❑ ❑ 01 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ Cl ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C3 ❑ <br /> :3 —LJ ❑ ❑ 13 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed describe what was done with the water after completion of tests: <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: Date 12/16/2009 <br />