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47 <br /> S W RCB,January 2002 OCT 2 6 2010 Page,of <br /> Secondary Containment Testing Rpt.. ormlry <br /> This form is intended for use by contractors performing periodic testing of UST seconc y coiitainnter?tsystems. Use the <br /> appropriate pages of this form to report results for all components tested. The comh7et�df6rm;wrdreh 61 procedures, and <br /> printoutsfrom tests(f applicable),should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 76 Date of Testing: 11-16-09 <br /> Facility Address: 5611 WATERLOO RD <br /> Facility Contact: PAUL Phone: 209-931-2942 <br /> Date Local Agency Was Notified of Testing: 11-13-09 <br /> Name of Local Agency Inspector(f present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: Tank Tester,Tec icain License Number: 04-1677 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training-Exvires <br /> INCON TS STS 10-13-1010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 SEC LINE X ❑ ❑ C ❑ ❑ ❑ ❑ <br /> 91 SEC LINE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 STP SUMP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISP 1-2 ❑ X ❑ ❑ ❑ ❑ ❑ <br /> DISP 3-4 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Transported as test fluid <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fac ated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />