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01 0 <br />1111� !!! jjj'��11111111111��l <br />111 t M1 MUM <br />This form is intended for use by contractors performing <br />periodic testing of USTsecondaiv containment sisleins. Useih <br />appropriate pages ofthisfbrin 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 ownerloperatorfir submittal to the local regulator agency. <br />I- FACII.ITV INFORMATION <br />Facility Name: <br />GEORGE KISHIDA TRUCKING Date of Testing: 11/3/2015 <br />Facility Address: <br />1.725 ACKERMAN DR, LODI County SAN 30AQt IN <br />Facility Contact: <br />KELLI I Phone: 209-368-0603 <br />Date Local Agency <br />Was Notified of Testing Wednesday, August 19, 2015 <br />Name of Local Agency Inspector (ij'present during testing): N/A <br />Component <br />Component <br />DSL -1 STP <br />DSL -1 SEC PIPING 04 <br />"N <br />'DSL -2 SEC PIPfNG <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK AS TEST WATER <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: <br />5n-,/�� Date: 11/3/2015 <br />Secondary Containment Test Results 1 of 5 <br />