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RECEIVED <br />swizcB, January aooa 0 C T 2 1 gJ3-1— of -7— <br />Secondary Containment Testing Report F <br />ffIRONMENTAL <br />This form is intended for use by contractors performing periodic testing of UST secondary containnl4&AV*@EPAfijWjNT <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: CRLLC #5446 1 Date of Testing: 101812013 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS I Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 9126113 <br />Name of Local Agency Inspector (f present during testing): NONE PRESENT <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: �,—�- U�—s Date: 10/8/2013 <br />103 <br />0 <br />MME <br />0 <br />. - _____ <br />► <br />o00 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: �,—�- U�—s Date: 10/8/2013 <br />