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SWRCB, January 2002 is <br />0 <br />Page I 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 <br />appropriate pages of this form 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 ownerloperaiorfor submittal to the local regulatory agency. <br />Faciliti Name: VERIZON-MANTECA CO Date of Testing: September 03, 2008 <br />Facility Address: 430 W. CENTER ST. MANTECA CA. 95336 <br />Facility Contact: MASOOD CHOLTDHLJRY —TPhone: 909-613-1553 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present (ii(present during testing): N/A <br />') TFC CT CONTRACTOR INFORMATION <br />Corn any Name: SUNWEST ENGINEERING <br />Technician Conducting Test: LEONARDO AGUILAR & DIMAS RAMIREZ <br />Credentials: X CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: General Engineering "A" <br />7 <br />License Number: 703190 <br />Manufacturer <br />Manufacturer Training <br />Cam Donent(s) Date Training Expires <br />(Fill in Tank I NUFACTURING <br />Underground Storage Tank Never Expires <br />Incon TS -STS Sump Testing System <br />Testing §Xstem 9/17/09 <br />11011 LM 1A MEN ILWA93 a I W2 IMMURM <br />If hvdrostatic testing was verfomed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TE �NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts d in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: September 03, 2008 <br />Revision: 0 <br />U <br />�UPPLY LINE& RETURN LINE (GENER 4TOR) <br />rMUMM <br />!�SPILL BUCKET <br />TANK INTERSTITIAL <br />If hvdrostatic testing was verfomed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TE �NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts d in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: September 03, 2008 <br />Revision: 0 <br />U <br />