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08/20/2003 06:44 7753584 1 <br />LA PERKS <br />11 <br />PAGE 02 <br />Page 1 of 2 <br />This fisrm is inlended for use by contractors,performing periodic testing of UST secondary containment systems. Use the appropriate <br />page,v of this form to report results far all components tested The tompleted form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submtinal to the total regulatory agency. <br />I W A rTT .Tf`V 1MYi4' DU A TTAN <br />Facilit Name: uik Stop #124 San Joa uin Coun Date of Testing: 8/14/03 <br />Fa,cilit Address: 505 No, Main St. Manteca, CA 95336 <br />Facili Contact: A.R &Sons Co <br />Phone: 209-823-7628 <br />Coun Contact:�Fol <br />Phone: 209-468-3451 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present: <br />2. V sus_, ;i• INFORMATION <br />License Type and #: A C-36 HAZ #678948 <br />Training by Manufacturer <br />Number of Tanks Tested: 0 _ <br />Number of Submersible Pump <br />Number of Fill Sumps "Tested:0 <br />3, SUMMARY OF TEST RESULTS <br />Number of Pipin Runs Tested.0 <br />Tested:0 Number of UDC Boxes Tested:0 <br />Number of Overfill Boxes Tested: 3 <br />Component <br />Pass <br />Fail <br />Comments <br />87 fill <br />X <br />❑ <br />Passed 8/14/03 <br />89 fill <br />X <br />0 <br />Passed 7/17103 <br />91 fill <br />X <br />❑ <br />Passed 5/15/03 <br />❑ <br />❑ <br />❑ <br />❑ <br />This is a re -test of the 87 fill that failed on 7/17/03 bucket was rSp&rW <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />C7 <br />❑ <br />❑ <br />❑ <br />Technician's Signature: <br />Date: 0 a- <br />