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09/22/2010 10:28 209-465-4988 HMC HENDERSON MAIN PAGE 08/11 <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 /> appropriatepages of thisform to report results for all components tested The completed form,written testprocedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACMITY INFORMATION <br /> Facility Name: TEXACO I Date of Testing: 6-22-10 <br /> Facility Address: 1405 CALIFORNIA ST,ESCALON,CA 95320 <br /> Facility Contact: CHOCO I Phone: 209-838-7674 <br /> Date Local Agency Was Notified of Testing: 6-17-10 <br /> Name of Local Agency Inspector(if present during testing): Twee <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: Service Technician License Number. 041677 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> OPW SPILL BUCKET 2-28-2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 SPILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 SPILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DSL SPILL BUCKET X ❑ D ❑ D D ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:� �_ <br />