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SWRC13,.lanuary 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This forrs is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropr/ate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printout::from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 76 EXPRESS Date of Testing: 6/1/09 <br /> Facility Address: 419 S.MAIN,MANTECA,CA 95366 <br /> Facility Contact: BOBBY Phone: 209-401-5131 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFO%MATION <br /> Compa:iy Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License: Type: Tank Tester,Technicain License Number: 04-1677 <br /> Manufacturer Training <br /> l4anufacturer Component(s)) Date Training Expires <br /> INCA N TS STS 10/13/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail \ot Repairs <br /> _ Tested Made Tested Made <br /> DISPI3NSER 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> _ ❑ ❑ ❑. ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ :1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Transported as test fluid <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts st in this document are accurate and in full compliance with Legal requirements <br /> Technician's Signature: Date: Cl/ <br />