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6 <br />SWRCB, January 2002 Page 1 of 7 <br />Secondary Containment Testing Report Form <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 Choudhury 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 UUNIKAUIUK INI•VKIVIAIIUIN <br />3. SUMMARY OF TEST RESULTS <br />Compone <br />cafflis" <br />RN <br />►=� <br />��� <br />MOM-; <br />' 'ly Line (Polisher) <br />Tiping Sump <br />Spill Bucket <br />Tank Interstitial <br />F-3 <br />01 <br />M <br />M <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 documentare accurate and in full compliance with legal requirements <br />Technician's Signature: bAam&b!� au Date: 9/08/05 <br />Revision: <br />