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SWRCB, January 2002 9 <br />Page 1 of 7 <br />6 -Month Testing <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Verizon Manteca Central Office Date of Testing: 09/08/05 <br />Facility Address: 430 W. Center Street, Manteca, CA 95336 <br />Facility Contact: Masood Choudhary Phone: (909) 613-1553 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: SunWest Engineering Constructors, Inc. <br />Technician Conducting Test: Brandon Reilly & Jorge Brito <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: General Engineering "A" License Number: 703190 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Joor Manufacturing, Underground Storage Tank, Never Expires. <br />Incon TS -STS Sump Testing System (See Attached) <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Transported to next test facility. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document re accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 9/08/05 <br />Revision: <br />Supply & Return Line (Polls er) <br />100MM <br />Supply Line (Polisher) <br />Piping Sump <br />Bucket <br />Tank I -nterstitial <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Transported to next test facility. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document re accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 9/08/05 <br />Revision: <br />