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SWRCB,January 2002 Page 1 of 1 <br /> Secondary Containment Testing Report Form ECS <br /> Ygjo <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment s <br /> pages of this form to report results for all components tested. The completed form,written test procedures, and printouts from <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. MAY 1 5 •?014 <br /> 1. FACILITY INFORMATION <br /> Facility Name:MARCH LANE 76 jDate of Testing:4/23/2014 <br /> Facility Address: 1206 E.MARCH LANE ,STOCKTON,CA 95210 NT <br /> Facility Contact:KARAM SINGH Phone:510-926-7834 <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:Timothy Elebeck <br /> Credentials: M CSLB Licensed Contractor r.1 SWRCB Licensed Tank Tester <br /> License Type: ILicense Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SB 9/7/2015 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box 1 regular fill X <br /> Spill Box 2 premium fill X <br /> Spill Box 3 diesel fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER WAS PUMPED OUT AND TAKEN AS TEST WATER <br /> CERTIFICATION OF TECIINICIAN 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: `� ""� 9 "� Date: 4/23/2014 <br /> WO:2317840 <br />