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A <br /> i <br /> SWRCB,January 2002 Page of <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION- <br /> Facility Name: MCI-Manteca Date of Testing: 11-01-2005 <br /> Facility Address: 2551 E.Louise Manteca,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Tank Specialists of California <br /> Technician Conducting Test: Jesse Arias <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A-B,HAZ License Number:745065 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon Incon Sump Testing Monitor System 12-01-06 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 1-Annular X <br /> 1-Sump X <br /> 1-Secondary Line X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATI O CLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge he f t s e docum are c d in full compliance with legal requirements <br /> Technician's Signature: Date: '! <br /> P4r <br /> °� CIFO� <br />