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SWRCB, January 2002 E E <br />0 Page I of 2 <br />Secondary Containment Testing Re5 <br />This form is intended for use by contractors performing periodic testing of UST secondWV4"h �&A4H Use the <br />appropriate pages of this form to report results for all consponents tested The completedfiW4�,W&cedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperalorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Verizon -Manteca Central Office Date of Testing: 11/14/05 <br />Facility Address: 430 W. Center Street, Manteca, CA 95336 <br />Facility Contact: Masood Choudhury Phone: (909) 613-1553 <br />Date Local Agency Was Notified of Testing: 11/10/05 <br />Name of Local Agency Inspector Present (if present during testing): <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Supply Line & Return Line (Polisher) <br />0 <br />oor� <br />0000� <br />0000 <br />00��� <br />0000 <br />0000 <br />0000 <br />mo00 <br />0000 <br />a000 <br />MMM <br />momm0M00 <br />0000 <br />ammo <br />000� <br />oa�o' <br />0000 <br />000 <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 requirements <br />00 <br />Technician's Signature:_ k�K� -�e� Date: 11/14/05 <br />