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SWRCB,January 2002 Page 1. <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 /> Facility Name: TE I CHERT CONSTRUCTION Date of Testing: 02/25/2008 <br /> Facility Address: 120 FRANK WEST CIRCLE STOCKTON, CA, 95206 <br /> Facility Contact: GEORGE Phone: (916) 386-3716 <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: TANKNOLOGY, INC. <br /> Technician Conducting Test: DANIEL ROLLINS <br /> Credentials: E CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Ma <br /> Spill Box 1 DIE FILL F- F-1 El ❑ I L � 0 <br /> Spill Box 2 UNL FILL X ❑ ❑ 0 El El <br /> Spill Box 3 WAS FILL 1X <br /> F❑ El E] ❑ E] El El <br /> El- <br /> ED 1:1 0 0 0 ❑ El EL <br /> 0 0 0 El 0 0 El El <br /> D ❑ ❑ ❑ 0 0 0 I--]-- <br /> El <br /> 0 0I 0 0 E 0 0 1-1 <br /> El ❑ ❑ 0 0 0 <br /> El 0 0 0 0 El F-1 <br /> 0 0 ❑ ❑ ❑ 0 0 jFE-]11 1:11010 0 0 Eli <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, theef�facts stated in this document are accurate and in full compliance with legal requirements <br /> 17, <br /> Technician's Signature: C-' f O t C 1"A-S Date: 02/25/2008 <br />