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12/0612010 14:35 209-465-4988 HMC HENDERSON MAINT PAGE 01103 <br /> ° <br /> • '"ter: ..�- - � �; <br /> SWRCB,January 2002 <br /> L <br /> of <br /> Secondary Containment Testing Report Form <br /> 7�Sis form is irrrended for►sae by cor�ractors perform+in$Pe�iodic testing of UST saaorrdars'cont�rvnent cyst o A L?°d COUNTY <br /> Y <br /> *�� ;?=ia1TAt <br /> 4ppropriate pages of this foam to report results for all components tested The r_ompleted for,tvrittera test, i AL � <br /> printow from tests(f applicable),should be provided to the facility ownerloperator for submittal to the local �� <br /> 1. FAC INFORMATION <br /> Facility Name: 76. Date o£Testi:ng: 12.01-09 <br /> Facility Address: 5611 WA'T'ERLOO? <br /> Facility Comte PAUL Phone: 209-931-2942 <br /> Date Local AgctM Was No f'red of Testing: 11-30-09 <br /> Name of Local A„•ency Inspector•(ff present during testing): GUM Baclats <br /> 2. TESTING CONTRACTOR RWORMATION <br /> Company Name: SST-Service Station Testing <br /> Tedinician Coacfiic mg Tea: Heath A.McEver <br /> Credentials: 0 CSLB-Licensed Contractor 13 SWRCB Licensed Tarok Tester <br /> License Types Tank Tester,Tecbnicain Licensee Nmnber: 04-1677 <br /> • ManutacEar+ar Tmfiafmiva€ <br /> Maiiiifacturer C ends) Date Traizz Exphm <br /> INCON TS STS <br /> 3. SUMMARY OF TEST]RESULTS <br /> Het Not <br /> Component Pass X:a1 Tested Made Component IPaas Fait 1f Made <br /> Dispenser 1-2 x 0 0 0 0 0 ❑ 0 <br /> Di 3-4 x 0 0 ❑ 0 0 Q ❑ <br /> Q O 0 ❑ 0 0 0 0 <br /> ❑ ❑ 0 ❑ 0 0 0 0 <br /> ❑ 0 0 0 0 0 0 ❑ <br /> ❑ ❑ ❑ ® ❑ 0 a 0 <br /> 0 0 Q ❑ ❑ 0 0 <br /> ❑ 0 0 0 0 0 <br /> 0 .3 ❑ ❑ QLO <br /> 0 0 <br /> 0 a ❑ 0 0 00 :30 0 ❑ ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after completion Otte= <br /> Tranworted as test fluid. <br /> CERTIFICATION OF 72CIMCIAN RESPONSIMP,FOR CONDUCTING TWS TESTING <br /> To the best of my knowledge,the f in this docttmad are acerc we and Lt full cora PAaj e,with kg4,,vwdrwww <br /> Tedmician's Sipature. � � <br />