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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> Thu form is intended for use by contractors performing periodic testing o�UST secondary containment systems. Use the <br /> appropr,ate pages of this form to report results for all components tested I The completed form written test procedures, and <br /> printout:*from tests(if applicable), should be provided to thefacility ownekoperator.for submittal to the local regulatory agency. <br /> _ 1. FACILITY INFORMATION <br /> Facility,Name: 76(MANTECA EXPRESS) Date of Testing: 5-1 1-09 <br /> Facilito Address: 419 S.MAIN,MANTECA,CA 95366 <br /> Facility Contact: BOBBY PHONE 209-401-5181 <br /> Date Local Agency Was Notified of Testing: -09 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFC RKATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor iKSWRCA Licensed Tank Tester <br /> License Type: Tank Tester,Technicain License Number: 04-1677 <br /> Manuf2ewrer Tra' in <br /> Manufacturer Com nen s Date Training Expires <br /> INCON TS STS 10-13-10 <br /> i <br /> 3. SUMMARY OF TEST R4ULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> _ Tested Made Tested Made <br /> 87 A'1NULAR SPACE X ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 KNNULAR SPACE X ❑ ❑ ❑ ❑ :1 ❑ ❑ <br /> DSL ANNULAR SPACE X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 87 SEC LINE X ❑ ❑ ❑ ! ❑ ❑ ❑ ❑ <br /> 91 SEC LINE X _j ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> DSL SEC LINE X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> 87 SIT SUMP X ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> 91 STP SUMP X ❑ ❑ ❑ ' ❑ O ❑ ❑ <br /> DSL STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 1-2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 3-4 ❑ X ❑ ❑ [I ❑ El ❑ <br /> El ❑ 11 ❑ El ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN DRUM ON SITE <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE l OR CONDUCTING THIS TESTING <br /> To the)mst of my knowledge,the facts state this document are accuiate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br /> i <br /> I <br />