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Seconds Containment Testing Report orm <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of <br /> this form to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable), should <br /> be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION CLLC: LODICA01 GEOPAR: UE-020 <br /> Facility Name: SBC I Date of Testing: 8/5/05 <br /> Facility Address: 124 W.ELM STREET LODI,CA <br /> Facility Contact: TOM WILLIAMS I Phone: 209-578-7178 <br /> Date Local Agency Was Notified of Testing : 48 HOURS PRIOR <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: PHILIP FLUTY <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A ASB HAZ B C-10 License Number: 588-098 sm <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHILTITE 5-GALLON SPILL BUCKET <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> DIESEL SPILL BUCKET ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ b ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL TEST WATER WAS LEFT ON SITE <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 <br /> requirements <br /> Technician's Signature: Date: 8/5/05 <br /> � c�c flut <br />