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SWRCB January, 20f}2 � Page of <br /> Secondary �;ontalnment Testing Report ,+orm !° <br /> Thisform is intended for use by contractors performing periodic testing of UST secondary containment systems, Use the VED <br /> appropriate pages of this form to report results for all components tested. The coo leted orm, written test proced ]� <br /> printouts rom tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatop�y ey'002 <br /> 1. FACILITY INFORMATION i'.'t� <br /> Name: Stockton, CA Switch Date of Testing: 91231200Z� LTy <br /> cility Address: 3807 Coronado Ave Stockton CA 95204 <br /> Facility Contact: Ron Williams <br /> TPane; 209.937-580 -- <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 Name: Shirley Environmen a es mg <br /> Technician Conducting Test: Paul Magana <br /> Credentials: ®CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: 798892 <br /> Manufacturer Traianin� <br /> Manufacturer Component(q) Date Training Expires <br /> A <br /> \01 l 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> STP DSL X <br /> k A X' <br /> Press Ann X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 in full compliance with legal requirements <br /> Date: 9/2312002 <br /> Technician's Signature: <br /> 4--,,— <br />