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I W/O#: 170712-291 <br /> Secondary Containment Testing Report Form <br /> This firm is intended for use Iry contractors performing periodic testing of UST secondary containment sYstenrs. Use the <br /> appropriate pages of this firrm 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•subrnittal to the local regulatory agency. <br /> �. FACILITY INFORMATION <br /> Facility Name: Manteca CO Date of Testing:08/24/17 <br /> Facility Address: 430 W.Center Street.Manteca,CA 95336 <br /> Facility Contact: Walley Riggs Phone (209)239-0251 ❑ Initial [ Repair Test <br /> Date Local Agency Was Notified of Testing: :16 Month L:Other <br /> Name of Local Agency Inspector(if present during testing): CESAR RUVALCABA V.1"friennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest Engineering Const.,Inc. <br /> Technician Conducting Test: Leonardo Aguilar laguilar@sunwestengineering.com <br /> Credentials: ❑CSLB Licensed.Contractor ❑SWRCB Licensed Tank Tester ❑✓ ICC UST Service Technician <br /> License Type: 5302718-UT License Number:703190 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON TS-STS 11/23/17 <br /> JOOR UST NEVER EXPIRES <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass hail Not Repairs Component Pass Fail: Not Repairs <br /> Tested Made Tested Made <br /> FILL SUMP ✓❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> PIPING SUMP ld ❑ LJ LI U Li L7 EJ <br /> SUPPLY/RETURN 1 Cl✓. ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> SUPPLY/RETURN 2 C✓d ❑ ❑ ❑ Li ❑ LJ ❑ <br /> SUPPLY LINE U ❑ ❑ ❑ LI ❑ Li ❑ <br /> ANNULAR SPACE 6J, ❑ ❑ LI LI U <br /> ❑ ❑ ❑ ❑ ❑ ❑ LJ <br /> ❑ ❑ ❑ ❑ ❑ Ll U ❑ <br /> ❑ ❑ ❑ LJ ❑ 10 ❑ ❑ <br /> U ❑ U ❑ L1 Ll ❑ L1 <br /> ❑ ❑ ❑ ❑ ❑ L1 <br /> ❑ ❑ ❑ ❑ ❑ E ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT ON SITE IN 3 PROPERLY LABELED 55 GALLON STEEL DRUMS FOR PROPER <br /> DISPOSAL BY CLIENT. <br /> For any equipment capable of generating a print out of test results, you must attach a copy <br /> of the test report to this certification a System printout attached. <br /> aY <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING INi. <br /> To ttre best of my knowledge,the facts,stetted in this document are accurate and in full compliaRe�, Erluir t en <br /> OranY R+e-y <br /> ry taan$a°e.x4+AQ—Leonardo w <br /> S <br /> j a17Technician's Signature: E -sw. Date: 08/24(17 <br /> llargU <br /> es pertm za as s as arar <br /> QA/QC APPROVEDF2s ' <br /> 8/25/201712:26 PMBrandon B <br /> ".s l <br />