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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. e e <br /> appropriate pages of this form to report results for all components tested. The completed for s, nd <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for subm t agency, <br /> 1. FACILITY INFORMATION 4 2009 <br /> Facility Name: STOCKTON AASF I Date of Testing: 12/10/08 <br /> Facility Address: 2000 Stimson Rd. Stockton, CA. 95206 ENVIRONMEWIM <br /> Facility Contact: MSG Antonio Pica Phone: 209-983- : <br /> Date Local Agency Was Notified of Testing: 12/4/08 <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tank Team inc <br /> Technician Conducting Test: Hector Galindo <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: C-10,C-57,HAZ License Number: 512835 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date TrainingExpires <br /> Incon ST Secondary testing 10/10 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Re airs Component Pass Fail <br /> Component Pass Fail p Not Repairs <br /> Tested Made Tested Made <br /> Annular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary pipe x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Udc's x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill box x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WWrem PV-V 1.4 *. LWV6Ter 9e9t,2%zTott• <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofknow my dg the acts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:` Date: 12/4/08 <br />