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SWRCB,January 2002 • • Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic:testing of UST secondam 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 ftf applicable),should be provided to the.facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: USA #65 (N-903) I Dateof Testing: 07/05/2006 <br /> Facility Address: 2500 W. LODI AVE. 5 LOWER SACRAMENTO RD. , LODI, CA, 95242 <br /> Facility Contact: MGR - BOBBIE Phone: (209) 366-0703 <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: TANKNOLOGY, INC. <br /> Technician Conducting Test: RAYMOND SIMMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 87 ❑K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 89 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 91 E ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box dsl ❑ ❑ 1 ❑ 1 ❑ Ell ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ El El <br /> ❑ -J ❑ El ❑ ❑ E] El <br /> El El El 11 ❑ ❑ ❑ ❑ <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 /> Technician's Signature: d Date:_ 07/05/2006 <br />