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i <br />WRC137, January 2002 <br />Page _ of <br />Thisform 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 farm, written test procedures, and': <br />printouts front tests (if applicable), should be provided to the facility ownerloperator for suhmittal to the local regulatory agency, <br />1. FACILITY INFORMATION <br />Facility Name: H&M KWIK SERV Date of Testing: 6-11-14 <br />Facility Address; 2501 E. JACKSON <br />Facility Contact: HASSAN 'bone: (209) 839-3971 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ifpresent during testing): BEG El <br />2. TESTING CONTRACTOWENFORMATION <br />Company Name: LC SERVICES JUIV-r7;U -CU Pf <br />Technician Conducting Test: JOSE OCHOA <br />Credentials: 11 CSLB Licensed Contractor 0 SWRCI3 Licensed Tank Tester t:NVIHUNMENTAt H <br />License Type: License Number:706992 .1 DEPARTMENT <br />I <br />Manufacturer Training <br />I I I INCON SUMP TESTER 2-14-16 1 <br />KAW00-1ji-Ell Wgo] 00 9 WI <br />�. .LII ��� <br />rt r N <br />i ■ <br />�,� <br />{FU <br />aft <br />87 SEC. PRODUCT <br />SII a <br />A "Mus <br />W"I <br />91 SEC. PRODUCT <br />21MMSM"Ift M -MOM <br />5 <br />ie <br />a MP —Mra I L <br />mom <br />mom <br />arc <br />o <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 requiremab <br />Technician's Sipa`";: <br />