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0 0 1 W/O#: 1 1 <br />SW'RCB, January 2002 page 1 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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CA4784419 Manteca CO I Date of Testing: 8128/14 <br />Facility Address: 430 W. Center Street Manteca CA <br />Facility Contact: Masood Choudhurry Phone: 909-613-1551... <br />Date Local Agency Was Notified of Testing: H <br />Name of Local Agency Inspector Present (f present during testing): JeffWong <br />3. SUNINLARY OF TEST RESULTS <br />.__r I r r i� r <br />�� <br />^�r r.,...�_ <br />Componen■®® <br />r... r <br />� r ,r....lt <br />PIPING SUMP <br />M 112 9 lkvj US tH 90 a Will <br />0000 <br />raoo�■ <br />JUIR J tj W1j,,j Yj all Rizz 91 Q111 arin,MITTE101mm- <br />o <br />0000 <br />SUPPLY LINE polls r <br />alaoo <br />0000 <br />SPILL BUCKET <br />oac�o <br />ra000. <br />ANNULARSPACEo000 <br />0000. <br />MMMr•acac��■ <br />o�oora000 <br />a0000000 <br />r�c•�r�o <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 infill compliance with legal requirements <br />Dgbly sign� by Ind 4uilarfff W41471545 <br />Technician's Signature: =141129 Date: 8128/14 <br />Document Reviewed 8/29/20149:43 AMJustin Trelstad <br />Revision: QA/QC APPROVED <br />9/4/20142:30 PMM!ke P. B <br />