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0 <br />SWRCB; January 2002 <br />• <br />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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: SBC I Date of Testing: 10/19/04 <br />Facility Address: 907 LINCOLN ROAD STOCKTON, CA <br />Facility Contact: CALVIN I Phone: 209-473-5430 <br />Date Local Agency Was Notified of Testing: 48 Hours Prior — At Least <br />Name of Local Agency Inspector (if present during testing): None <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail Not <br />Tested <br />Repairs <br />Made <br />ANNULAR <br />FILL SUMP <br />PIPE SUMP <br />PIPE SECONDARY <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT ON SITE IN 3 DRUMS. REPORTED DRUMS TO ARMI @ 1:15 <br />CERTIFICATION OF ECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To tl:e best of my knowledge, thefall stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 10/19/04 <br />