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JAN -21 -2003 -TUE 01;17 PM <br />Dec 31 02 ll.:02a <br />SWRCB, January 2002 <br />Franzen Hill <br />556881467 <br />P. 002 <br />p.6 <br />Page l of %. <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 competed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the faclliry ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Food Less bate of Testing: 12/12/02 <br />Facility Address: 3434 Manthey Rd Stockton WON 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 (tf present during testing): <br />A- iEn4_11NU WN'1'IZACT0R INFORMATION <br />Company Name: Franzen -Hill Corp 1100 North J Street Tulare, CA 93274 <br />Technician Conducting Test: Felix Mendes <br />Credentials: x CSL13 Licensed Contractor 0 SWPC8 Licensed Tank Tester <br />License Type: A,B,C-61/D40 )4AZ License Number: 304147 <br />Manufacturer Training <br />Manufacturer Com onent s Date Training Expires <br />ftiviron Piping and Testing 10/03 <br />Total Containment Piping and Testing 10/03 <br />Incon Testing 09/04 <br />Cadwell Testing_ <br />2 0%iiM%4APV niP Tr4Q r Drcrri 're <br />If hydrostatic testing was perforated, describe what was done with the water after completion of tests: <br />�t P 0%1 54e_ �t S ` -,, 1r �r! l ...,. Ye 1—t 41 n c , -S o7 o 5 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are aceurate and In full compliance with legal requirements <br />Technician's Signature: r" ' ���'� � Date:___% .7- — /Z - <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Re airs <br />Made <br />Component <br />Pass <br />Fait <br />Not <br />Tested <br />6 <br />Made <br />nsnvt <br />D <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />11 <br />o:, <br />err. <br />tit <br />i <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />�] <br />❑ <br />❑ <br />0 <br />❑ <br />Q <br />❑ <br />D <br />❑ <br />fl <br />C <br />nuc <br />- <br />1-2- <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />If hydrostatic testing was perforated, describe what was done with the water after completion of tests: <br />�t P 0%1 54e_ �t S ` -,, 1r �r! l ...,. Ye 1—t 41 n c , -S o7 o 5 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are aceurate and In full compliance with legal requirements <br />Technician's Signature: r" ' ���'� � Date:___% .7- — /Z - <br />