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r % • • <br /> 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. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form,written test procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 76 Date of Testing: 12-01-09 <br /> Facility Address: 5611 WATERLOO <br /> Facility Contact: PAUL Phone: 209-931-2942 <br /> Date Local Agency Was Notified of Testing: 11-30-09 <br /> Name o ocal Agency Inspector(fpresent during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducti Test: Heath A.McEver <br /> Credentials: ❑CSL Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: ank Tester,Technicain License Number: 04-1677 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON TS STS <br /> 3. SUMMARY O EST RESULTS <br /> Component Pass Fail Not Repalirfi, Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Dispenser 1-2 X ❑ ❑ C ❑ ❑ ❑ ❑ <br /> Dispenser 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ :1 ❑ ❑ ❑ NEl ❑ <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 facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />