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SWRCB,January 2002 Page 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 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 /> F <br /> ility Name: VARLERO Date of Testing: 1-20-10 <br /> ility Address: 1001 E.YOSEMITE,MANTECA,CA 95336 <br /> ility Contact: BILLA Phone: 209-825-4569 <br /> e Local Agency Was Notified of Testing: 1-20-10 <br /> me of Local Agency Inspector(f present during testing): MUNI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester,Technicain License Number: 04-1677 <br /> Manufacturer TraininE <br /> Manufacturer Com nent(s) Date Training Expires <br /> SMITH 91 SECONDARY LINE 2-13-10 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91 SECONDARY LINE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ 1 . ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ C 1 0 0 ❑ <br /> 0 ❑ ❑ ❑ 0 ❑ 0 ❑ <br /> ❑ 0 ❑ 0 ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ 0 0 ❑ ❑ <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,thefa ted in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:, / 4?' <br />