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SWRCB January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This for it intended for use by contractors performing periodic testing of USTsecondary containment systems. Use the <br /> approp',iote pages of this form to report results jor all components tested The completed form, written test procedures, and <br /> printout from tests (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACIIdTY INFORMATION <br /> Facili ' Name: System Transport I Date of Testing: 5-31-11 <br /> Facili Address: 707 E. Roth Road,French Camp Ca 95231 <br /> Facilit e Contact: Sam Phone: 209-983-8062 <br /> Date I ocal.Agency Was Notified of Testing <br /> Name f Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comp ny Name: JP Petroleum Service _ <br /> Techn cian Conducting Test: Gabe Garcia _ <br /> Credej itials: x CSLB Licensed Contractor C°. SWRCB Licensed Tank Tester <br /> Licen Type: A License Number: 81 t471 ICC#5281582 <br /> Manufacturer Training <br /> anufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested I Made <br /> Ann ar 1 x U 7 ❑ ❑ C <br /> Line I x L U LJ ❑ ❑ ❑ U <br /> Line x ❑ ❑ U ❑ ❑ ❑ <br /> Line 5 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sum 1 x ❑ U ❑ ❑ ❑ U ❑ <br /> UDC 1&2 x ❑ Ll LI ❑ ❑ ❑ <br /> UDC Sat 1 x 11 ❑ ❑ CI ❑ ❑ ❑ <br /> UDC Sat 2 x ❑ U ❑ ❑ ❑ ❑ CJ <br /> ❑ ❑ ❑ ❑ <br /> ❑ I1 ❑ 1 ❑ ❑ L L - <br /> ❑ ❑ ❑ I ❑ -1 1 ❑ ❑ <br /> If hydr tatic testing was performed,describe what was done with the water after completion of tests: <br /> Wate was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,th fqFls toted in this d ument are qccurale and in full compliance with legal requirements <br /> Technician's Signature: <br /> `�` a%' L2 Date: 3 — f <br />