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r Q4/05/2010 10:17 209-465-4988 HMC PAGE 01/05 <br /> SWR.CB,January 2002 _ Page of__�_ <br /> APR 5 <br /> Secondary Containment Testing Report or?J16 <br /> This form is intended for use by contractors performing periodic testing of LIST secA04dimmotawms. Use the <br /> appropriate pages nf'this form to report results far all components tested Ticecoral��4cbrpn` vrrttdheot procedures,and <br /> printouts from tests(if'applicable),shoidd be provided to the facility owner/operator JOr if l a thkrlacal regulatory agency. <br /> 1. FACELITY INFORMATION <br /> Facility Name: COUNTRY SIDE MINI MART Irate of Testing: 2-23-10 <br /> Facility Address: 14971 HWY 88,LODI,CA 95240 <br /> Facility Contact: EDDIE _ Phone: 209-968-8553 <br /> Date Local Agency Was Notified of Testing: 2-2-10 4 <br /> Name of Local Agency Inspectorif present during resting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: C CS LB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank'Tester,Technicain License Number: 04-1677 <br /> Manufgcturer Traininz <br /> Manufacturer Com nent s Date Trainin E ices <br /> INCON _ TS STS 10-13-10 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 98191./DSL ANNULAR X ❑ ❑ ❑ I ? ❑ 01 0 <br /> 87 SECONDARY LINE X ❑ 0 ❑ c ❑ <br /> 91 SECONDARY LINE X ❑ ❑ r ❑ ❑ ❑ ❑ <br /> DSL SECONDARY LINE x ❑ ❑ ❑ ❑ ❑ n <br /> 87 STP SUMP x (i ❑ ❑ ❑ 0 n <br /> 91 STP SUMP X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> DSL STP SUMP -X Ll (::i t1 0 <br /> DISPENSER 1-2 X ❑ ❑ ❑ !✓- i]� ❑ C' <br /> DISPENSER 3-4 X ❑ ❑ ❑ ❑ I :! <br /> ❑ ❑ ❑ ❑ (] C? ❑ J <br /> i.i ❑ U ❑ r-7 [.:I ❑ <br /> ❑ il C.1 ❑ ❑ (� C7 1�7 <br /> .If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Transported as test fluid_ <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 itr full compliance with legal requirements <br /> Technician's Signature:, Date:—- <br />