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9255517899 Line 1 0006 p.m. 10-19-2010 2/8 <br /> 20.562307 <br /> ' <br /> SWRCB,January 2002 Page 1 of 7 <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 test procedures,and <br /> printouts from tests(ifapplicable),should be provided to thejacility ownerloperatorjorsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:PG&E Date of Testing:10/1112010 <br /> Facility Address:4040 West Lane <br /> Facility Contact:Alex Steele Phone:209.337-8902 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Getter-Ryan Inc <br /> Technician Conducting Test:C.Bishop <br /> Credentials: NCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A License Number:220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not I Repairs <br /> Tested Made ITestedl Made <br /> Used Oil lc] ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Cl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ J <br /> ❑ <br /> 11 ❑ ❑ ❑ 11 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <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: a 13 Date:10/11/2010 <br />