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f <br />2560 Soquel Avenue Ste 2 <br />Santa Cruz CA 95062 i�- <br />T: 831.475.8141 <br />F: 831.475.8249 <br />CA Lic# 693807 A-HAZ B-HIC <br />Secondary Containment Testing Report Form <br />1. Facility Information <br />Facility Name: Valero 3641 <br />Date of Testing: 09/15/2009 <br />Facility Address: 1210 E. Hammer Ln. Stocton CA 95210 <br />Facility Contact: <br />Phone: 2 094-773-111_ <br />Date Local Agency Was Notified of Testing: 09/22/2009 <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. Testing Contractor Information <br />Manufacturer: <br />Component: <br />Expiration Date: <br />Incon <br />I Leak Detector <br />11/27/2010 �I <br />3. Summary of Test Results <br />Is this a retest of previously failed components? .YES <br />Component <br />P <br />I F <br />I NT <br />I RM <br />Component <br />P <br />I F <br />NT <br />I RM <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Spillbox <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 <br />legal requirements <br />Technician's Signature: Date: 09/15/2009 <br />Technician's Name: Rudi Chavez <br />