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SWRCB, January 2002 Page 1 of 7 <br />Secondary Containment Testing Report Form <br />This form is intendedfor 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Food 4 Less Date of Testing: 12/12/02 <br />Facility Address: 3434 Manthey Rd Stockton WO# 111063 1:30 PM <br />Facility Contact: Gary Pforr Phone: 925-674-6707 <br />Date Local Agency Was Notified of Testing: 12/10/02 <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Franzen -Hill Corp l 100 North J Street Tulare, CA 93274 <br />Technician Conducting Test: Felix Mendes <br />Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A,B,C-6liD40 HAZ License Number: 304147 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Environ Piping and Testing 10/03 <br />Total Containment Piping and Testing 10/03 <br />Incon Testing 09/04 <br />Cadwell Testing <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />�-16 I- o,i 5t 1 e- C,(,ti {r w I'll rerr•�rc t.,n j c/, Cl <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: C'�" �/l�1�<�l � Date: / )- ` t7 — G 1�- <br />---JMM�F. <br />M <br />M01 <br />ME■ <br />mom <br />MMMM <br />MM <br />Mm==! <br />: <br />o0o <br />a000 <br />�o <br />0000 <br />r�aoo <br />0000 <br />0000 <br />0000 <br />0000 <br />0000. <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />�-16 I- o,i 5t 1 e- C,(,ti {r w I'll rerr•�rc t.,n j c/, Cl <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: C'�" �/l�1�<�l � Date: / )- ` t7 — G 1�- <br />