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S WRCR, January 2002 <br />Page 1 of 7 <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 appropriate pages <br />of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1_ F A rTT .TTV TN1l nD M A T1fn1%J <br />Facility Name: z /,.r/ Z <br />Date of Testing: <br />Address: 330 '-T"W L <br />.Facility <br />Facility Contact: ®,fir .c3 <br />Phone: - 2 <br />Date Local Agency Was Notified of Testing:_ 7 <br />Name of Local Agency Inspector if 2resent during testing) rt i CSC ->"LL'' L &.:— -� <br />Com anName: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: y '-k- <br />Credentials: <br />kCredentials: [X ] CSLB Licensed Contr ctor [ l SWRCB_Licensed Tank Tester <br />License T e:. C -61/D40 HAZIHIC License Number: 309105 <br />Manufacturer <br />Manufacturer Trainine <br />1 / \ / - ► •' <br />Date Train <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />s7OP <br />W 3PIIIC IW144L <br />zIerg &—L <br />I <br />i <br />--i <br />1 <br />J <br />i nyarostattc testing was periormea, aescrtne what was pone 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 requirements. <br />Technician's Signature: Date: ___ <br />