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t. _ I r 0 <br />SWRCB, January 2002 <br />11 <br />Secondary Containment Testing Report Form <br />Page 1 of 7 <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 />FACII.TTV INFORMATION <br />Facility Name: VER-MANTECA CO I Date of Testing: September 01, 2011 <br />Facility Address: 430 W. CENTER ST. MANTECA CA. 95336 <br />Facility Contact: MASOOD CHAUDHURY Phone: 909-613-1553 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present (if present during testing): MUNIAPPA NAIDU <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Sun West Engineering <br />Technician Conducting Test: LEONARDO AGUILAR <br />Credentials: N 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 />(Fill in Tank Info): JOOR MANUSFACTURING UST NEVER EXPIRES <br />Incon TS -STS Sump Testing System INCON TS -STS 11/20/11 <br />3. SUMMARY OF TEST RESULTS <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 fisll compliance with legal requirements <br />ra <br />Technician's Signature: Date: September 01, 2011 <br />Revision: <br />SUPPLY LINE POLISHER <br />SPILL BUCKET <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 fisll compliance with legal requirements <br />ra <br />Technician's Signature: Date: September 01, 2011 <br />Revision: <br />