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MRCB, January 2002 of <br />Secondary Containment Testing Report Form <br />Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Usethe <br />appropriate pages of this form to report resultsfor all components tested. The completedform, written test procedures, and <br />t nlictble). should be provided to the facility ownerloperatorfor submittal to the local regulatory agencl. <br />FacilityI Name: Stockton AASF y Date of Testing: 12/11/02 <br />Facility. Address: 2000Stimson Road, Stockton CA 95206 <br />Facility Contact: SFC Curt LancePhone: 209983.5331 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency inspector (if present during testing): 2 men <br />itrFill, �?,,�114 , , �11 01 <br />Company Name: Central Coast Tank Testing <br />Technician Conducting Test: Robert Hankenson <br />Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: <br />License Number: CA 91-1169 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />NWITINWIM <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAN RESPONSEBLE FOR CONDUCTING TMS TESTING <br />I'll, 11, j.- . "I .. f " , fisfl conwfiance with leval requirenwnts <br />Technician's Signature: Date: <br />13111 oil] I ly <br />M <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAN RESPONSEBLE FOR CONDUCTING TMS TESTING <br />I'll, 11, j.- . "I .. f " , fisfl conwfiance with leval requirenwnts <br />Technician's Signature: Date: <br />