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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 /> appropriate pages ofthis form to report resultsfor all components tested. The completed form, written testprocedures, and <br /> printouts from 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: KWIKSERV I Date of Testing: 10-17-13 <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. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fall Not Tested Modes <br /> Tested Made <br /> REGULAR STP ❑ ❑ © ❑ REGULAR FILL ® ❑ ❑ ❑ <br /> PRENIIUM STP ® ❑ ❑ ❑ REGULAR VAPOR ® ❑ ❑ ❑ <br /> PLUS STP ® ❑ ❑ ❑ PLUS FILL ® ❑ ❑ ❑ <br /> REGULAR PROD SEC ❑ ❑ ❑ PLUS VAPOR ❑ ❑ ❑ <br /> PRENEUM PROD SEC ® ❑ ❑ ❑ PREMIUM FILL ® ❑ ❑ ❑ <br /> PLUS PROD SEC ❑ ❑ 0 ❑ PREMIUM VAPOR ® ❑ ❑ ❑ <br /> PRENIIUM/PLUS ANN. ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER ''/Z ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 3/4 ❑ ❑ © ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 5/6 01 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 7/8 ❑ 1 ❑ 1 ® 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 FFB I i �-- — <br /> VIRON 4F irw� <br /> MLALTH DEPARTMENT <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge th is stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature Date: /'////3 <br />