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SWRCB, January 2002 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systemfEj3g,#* 2014\ <br />appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the , '000 <br />EN *RATWLTH <br />1. FACILITY INFORMATION PERMIT/SERVICES <br />Facility Name: Teichert Mobile Equipment <br />Date of Testing: 1/17/14 <br />Facility Address: 120 Frank West Circle, Stockton Ca 95206 <br />Facility Contact: Steve Schamaun I Phone: 916-386-3767 <br />Date Local Agency Was Notified of Testing: 1/10/11 <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name: JP Petroleum Service <br />zm� <br />Technician Conducting Test: Gabe Garcia <br />Credentials: x CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: A <br />License Number: 811471 ICC # 5281582 <br />Manufacturer <br />Manufacturer <br />Component(s) Date Training Expires <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />- Water was filtered and retumed to holding tank. <br />Technician's Signature: Date: <br />zm� <br />Component <br />MM <br />OEM <br />' <br />ar»o� <br />�or.��oo' <br />000000 <br />o000 <br />- <br />oi000© <br />Mom=oao' <br />�, - - <br />o <br />000000 <br />- <br />��oo� <br />0000 <br />� 1-6 <br />1MNM1W1WnM= <br />No= <br />• <br />000000 <br />oo©o <br />0000 <br />000■o <br />�_ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />- Water was filtered and retumed to holding tank. <br />Technician's Signature: Date: <br />