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2560 Soquel Avenue Ste#2 • D IlM <br /> Santa CruzCA95062 <br /> ,8141 IT _ RECOl/ ED <br /> T: 831.475.8141 u 11 <br /> F: 831.475.8249 LCL <br /> CA Lic#693807 A-HAZ B-HIC , 1 9 2005 <br /> ENVIRONMENT HEALTH <br /> Secondary Containment Testing Report Form PERMIT/SERVICES <br /> 1. Facility Information <br /> Facility Name: Valero 3898 <br /> Date of Testing: 11/24/05 <br /> Facility Address: 153 E.11th St.Tracy CA 95378 <br /> Facility Contact: <br /> Phone: _20-983-2s15 <br /> Date Local Agency Was NotifiedTg: 11/21/2005 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. Testing Contractor Information <br /> Manufacturer Component Expiration Date <br /> [noon Leak Detector 06/05/06 <br /> 3. Summa of Test Results <br /> Component P F NT RM Component P F NT RM <br /> Secondary Piping 87 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3-4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> Technician's Signature: /L / Date: 12/09/2005 <br /> Technician's Name: Frank Bohnet <br /> ARD SCANNED <br /> 1of7 <br />