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. 16 InAl <br /> 4SWRCB,January 2002 0 R <br /> Secondary Containment Testing Repc A Form FEB 299 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. <br /> appropriate pages of this form to report results for all components tested. The completed form, writteg4�pj �cedures, and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operator for submittal to thp.j r,V _1�cEt24Hj1iZ;gency. <br /> 1. FACILITY INFORMATION HEaLrh t1Er.;"6 i ENr <br /> Facility Name: MANTECA VALERO Date of Testing: 12/01/2008 <br /> Facility Address: 1001 E.YOSEMITE <br /> Facility Contact: GEORGE Phone: (209)824-9282 <br /> Date Local Agency Was Notified of Testing: 11/24/2008 <br /> Name of Local Agency Inspector(fpresent 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 Component(s) Date Training Expires <br /> INCON TS STS TESTER 10/13/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91/DSL ANNULAR SPACE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 ANNULAR SPACE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 1-2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 5-6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISPENSER 7-8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TRANSPORTED AS TEST FLUID <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:— <br />