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.. 0'„'x+22/2003 11:39 77535 1 LA PERKS PAGE 02 <br /> Page a of Z <br /> Secondary Containment Testing Report For <br /> This form is twendedfor use by contractors performing ped0d is teM19 of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. Me completed form, written test procedures, acrd printouts from tests(ff <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACELM MFORMATION <br /> Facility Name: Quik§Loj2#121 resat),Joaquin Cour Date of Testi 5!19/03 <br /> R ifily Address: 1196 W Louise Ave. Manteca, CA 95336 <br /> Facili Contact:Gmath§x20& SturnohiU&r K= : 209-239-2957 <br /> Co Contact: NM Fol Phone: 209-468-3451 FX: 209-4683433 <br /> Date Local Agency Was Notified of Testim <br /> Name of Local Agog ctor Present, <br /> 2. TESTING CONTRACTOR E4FORMATIQN <br /> Com an Name:L.A.Perks Plumbing&Hea ' Inc. <br /> Technician Con Teat: <br /> Credentials: X CSLB Licensed Contractor d SWRCB Licensed Tank Tester <br /> License Ape=d.#. A,C-36,HAZ#678948 <br /> Trabdug by Mtnafactarer <br /> Manufac4u'ear Com <br /> CNI <br /> 3. SUARLARY OF TEST RnULTS <br /> Number of Tanks Tested: 0 Number of Piping Runs Tested:0 <br /> Number of Submersible Sump s Tested:0 Number of UDC Boxes Tested:0 <br /> Number of Fill Sum s Te :0 Number of OverIM Boxes Tested:2 <br /> Component PXU Fail Comets <br /> 87 Fill X o <br /> 91 Fill X <br /> ® 0 <br /> Q t� <br /> Q � <br /> o a <br /> 4 <br /> o a <br /> 0 <br /> Technician's Sipatwc: L Date: x/19/U3 <br /> SWRCB <br />