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S WRCB,January 2002 .Page of <br /> .4J1ATTNr ARIS-PARTL4t 6 MO. - Secondary Containment Testing Report <br /> Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written Fest procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operatoa•for submittal to the local regulatory agency. <br /> L FACILITY INFORMATION <br /> Facility Name: ECONO GAS I Date of Testing: 11-09-11 <br /> Facility Address: 880 E.VICTOR ROAD,LODI <br /> Facility Contact: MANISH Phone: 209-369-0958 <br /> Date Local Agency Was Notified of Testing: RIIOME DESBIENS <br /> Name of Local Agency Inspector(r(present during testing}: NONE <br /> 2. TESTING CONTRACTOR INFO TII)N <br /> Company Name: B.Z.Service Station Maintenance <br /> Technician Conducting Test: RIIOME DESBIENS <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: ICC License Number.433159 <br /> Manufacturer Trainini <br /> Manufacturer Com onent(s) Date Trainin Expires <br /> INCON TS-STS AUG 2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail Tested Made <br /> DSL SECONDARY LINE x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3 &4 X ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ LEI ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> D El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ EEI❑ ❑ ❑ ❑ El ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in thocument are accurate and In ft+ll compliance with legal requirements <br /> Technician's Signature: Date: 11-09-11 <br />