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SWRCB, January 2002 Page 1 . <br />Secondary Containment TestingReport 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 (zf applicable), should be provided to the facility owner/operator forsubmittal to the local regulatory agency. <br />Facility Name: TEICHERT CONSTRUCTION <br />DateofTesting: 03/02/2006 <br />Facility Address: 120 FRANK WEST CIRCLE STOCKTON, CA, 95206 <br />Facility Contact: GEORGE <br />Phone: ( 916) 386-3716 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <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 Gest of"my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: G�� Date: 03/02/2006 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />KELVIN CRUZ <br />gumm <br />Spill Box DSL -E <br />Credentials: <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />License Type. <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Spill Box 87 <br />3. SUMMARY OF TEST RESULTS <br />Spill Box W.OIL <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 Gest of"my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: G�� Date: 03/02/2006 <br />gumm <br />Spill Box DSL -E <br />Spill Box DSL -W <br />Spill Box 87 <br />Spill Box W.OIL <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 Gest of"my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: G�� Date: 03/02/2006 <br />