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Secon Containment TestifigRepcoFoirm <br /> This form is intended for use by contractors performing periodic testing of UST secondary con amment 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), <br /> should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION CLLC: LODICA01 GEO PAR: UE-020 <br /> Facility Name: SBC Date of Testing: 8/9/04 <br /> Facility Address: 124 W.ELM STREET LODI,CA <br /> Facility Contact: KATHY HALLIGAN Phone: 209-474-4514 <br /> Date Local Agency Was Notified of Testing: 48 HOURS PRIOR <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: BRIAN GONZALES <br /> Credentials: ® CSLB Licensed Contractor ❑ SWRC13 Licensed Tank Tester <br /> License Type: A ASB HAZ B C-10 License Number: 588-098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHILTITE 5 GALLON <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> DIESEL FILL <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: 8/9/04 <br />