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S WRCB, January 2002 Page I of <br />SSeconary Containment Testing Report Form. <br />Th form is intended for use by contractors performing periodic testing of US7 secondary containment e <br />appropriate pages of this form to report results for all components tested The completed form, writ >r� oc W1 <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to re ory agency. <br />I- FACILITY INFORMATION <br />Facility Name: City Of Stockton - Corp Yard Date of Testing: 1-3-13 <br />Facility Address: 1465 E. Lincoln Stockton, Ca 95206 <br />Facility Contact: Maria Phone: 209-937-5642 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during tesfing). Stacy <br />►; t►Y'i;!: ► �:��c I'll <br />Company Name. $eademn M3imefw= Company - MWC <br />Technician Conducting Test: <br />Charles Ferrucci <br />Credentials: G <br />0 SWRCB Licensed Tank Tester <br />License Type: <br />Technic ain License Number: 856771 <br />Manufacturer <br />Manufacturer TraininL► <br />Co nent(s) Date Training Expires <br />INCON <br />TS STS 12-29-13 <br />u <br />Q <br />u <br />u u <br />u <br />❑ <br />Component <br />p <br />Pass <br />Fad <br />Not <br />Tested <br />Repairs <br />Made <br />Component pass <br />Fail <br />Not <br />I Tested <br />Repairs <br />Made <br />DIESEL PROD LINE EAST <br />19 <br />u <br />Q <br />u <br />u u <br />u <br />❑ <br />DISPENSER 5/6 <br />® <br />❑ <br />❑ <br />0 <br />❑ ❑ <br />❑ <br />❑ <br />DISPENSER 7/8 <br />0 <br />❑ <br />0 <br />❑ ❑ <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />❑ <br />u <br />u <br />u <br />u u <br />u <br />❑ <br />❑❑ <br />0 <br />u u <br />0 <br />0 <br />If hydrostatic testing was performed, d =Jbe Wbal was d®nc -itb the water after completion of tests_ <br />Transported as test fluid. <br />CER CATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the ads st d in this do c nt are accurate anal in full compliance with legal requirements <br />yy <br />Technician's Signature: Date: 1 ' l <br />