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0 <br /> 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION 77 - <br /> Facility Name: VARLERO Date of Testing: 1-20-10 <br /> Facility Address: 1001 E.YOSEMITE,MANTECA,CA 95336 <br /> Facility Contact: BILLA I Phone: 209-8254569 <br /> Date Local Agency Was Notified of Testing: 1-20-10 <br /> Name of Local Agency Inspector(fpresent 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 Training <br /> Manufacturer Component(s) Date Training Expires <br /> SMITH 91 SECONDARY LINE 2-13-10 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91 SECONDARY LINE X ❑ El ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ El ❑ ❑ ❑ ❑ <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 fac ted in this document are accurate and infill compliance with legal requirements <br /> Technician's Signature: Date: r/ <br />