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SWRCB,January 2002 Page of <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 H&M KWIK SERVE BW98 Date of Testing 8/30/2017 <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: MIKE Phone: (209)838-3971 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC SERVICES <br /> Technician Conducting Test: PETER WESTBROOK <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: ICC I License Number:B46675 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON SUMP TESTER 7/20/2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 STP x ❑ ❑ 0 0 0 ❑ <br /> 91 STP x ❑ 0 ❑ ❑ ❑ ❑ <br /> DIESEL STP x ❑ 0 0 ❑ 0 ❑ ❑ <br /> UDC 1-2 x ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> UDC 3-4 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 0 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ o ❑ <br /> El ❑ ❑ ❑ ❑ ❑ El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> RETURNED TO HOLDING TANK. <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: Date: <br />