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O7/25/2003 09:35 7753584 11 LA PERKS PAGE 05 <br />is <br />Secondary Containment Testing Report Form Page 1 ofZ <br />T iris form Lt rnt fig* use by contractors performing periodic testing o. f UST sec cowartnment systems_ Use the appropraete <br />Pages ofthis form to report results for all cvnrponems tested The comPleted form, written test procedures, and printouts from tests (if <br />applicable), should be Provided to the faciltry owner/operator for submitral to the local regulatory agency. <br />. FACMFORMATION <br />Facility Name: Stop #124 Sart Jo uin County) of Te . :7117/03 <br />FacilityAddress: 505 No. St. Manteca,CA 95336 <br />Facility Contact: A.R !k Sons Co Phone: 2Q9-823»7628 <br />Cognty Contact: Kas y Fol Phone: 209-4683451 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Invector prewnt. <br />�om ariy Name: L.A.Perks Plumb" & H Inc. <br />echnician Con d icting Test: Keith Perks <br />:redentials: X CSL$ Licensed Contmctor Os CB Licensed Tank Tester <br />,icense T and #: A, C-36, HAZ #678948 <br />Troiningrw by Manufaeftrw 111 .-Mill 111111� <br />Manu&cTurcr <br />Technician's Si m T Dam: 7/17/03 <br />SWRCB <br />Page 2 of 2 <br />