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SWRCB,Rinuary 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 i om 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: VALERO I Date of Testing: 5/30/09 <br /> Facility Address: 1001 E.YOSEMITE,MANTECA,CA <br /> Facility Contact: KASEEM Phone: (209)824-9282 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: Tank Tester,Technicain License Number: 04-1677 <br /> Manufacturer Training <br /> Manufacturer Com nent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> _ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 91/D<<L ANN SPACE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 SEC LINE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ I ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ 0 0 ❑ 0 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ 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 hest of my knowledge,the facts sta do this document are accurate and in full compliance with legal requirements <br /> ,��Technician's Signature: Date:; <br />