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SWRCB,January 2002 RE ffr 4Vf.-D <br /> Secondary Containment Testing Report For y 1, 7 Z 0 18 <br /> Th isform 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 Yc <br /> /A <br /> A <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the D L <br /> Y <br /> f-NT <br /> 1. FACILITY INFORMATION <br /> Facility Name: Western Food&Fuel 77FDate of Testing: 5/15/2-0--18 <br /> Facility Address: 3032 Waterloo Rd Stockton Ca 95205 Phone: 209-321-1632 <br /> Facility Contact: Dave <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):John <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Elite IV Contractors <br /> Technician Conducting Test: Joe Bartholdi <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC UST Service Tech License Number:ICCO0042842 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Ex fres <br /> 3. SUMMARY-OF-TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <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 acts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br />