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0 0 Page_of <br /> SWRCB,January 2002 <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 testprocedures, and <br /> printoutsfrom tests(if 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 I Date of Testing: 2-11-14 <br /> Facility Address: 824E YOSEMITE AVE MANTECA CA 95336 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(i/present during testing):NONE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST <br /> Technician Conducting Test: CFERRUCCI <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON TS-STS <br /> 3. SUMNLIRY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fall Tested Made Component Pass Fall Tested Made <br /> REGULAR STP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 3/4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> REG PROD SEC LINE ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> PLUS PROD SEC LINE ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ 0 ❑ ❑ ❑ <br /> LjLj <br /> ❑ JE00 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ <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 /> . �'1t�fiilrmr <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, the fads stated in this document are accurate and in fudd compliance with legal requirements <br /> Date: <br /> Technician's Signature <br /> Z/�`� <br />