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SW RCB,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 /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(+f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: KWIK SERV Date of Testing: 2-11-14 <br /> Facility Address: 824E YOSEMITE AVE MANTECA,CA 95336 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing:NONE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST ENVIRON11 111-114—11-AL <br /> Technician Conducting Test: CFERRUCCI <br /> Credentials: ❑CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) __ _ Date Training Ea fres <br /> INCON TS-STS <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> REGULAR STP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 3/4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> REG PROD SEC LINE ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> PLUS PROD SEC LINE ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER TAKEN OFF SITE AT TEST WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, <br /> theefffa7cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: / Date: <br />