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SWRCB,January 2002 Page 1 of 7 <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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> [Facility Name:Anabi Shell Date of Testing:7/12/18 <br /> acility Address:2375 W Grant Line Rd.,Tracy, CA 95377 <br /> acility Contact:Manager Phone: <br /> ate Local Agency Was Notified of Testing :7/5/18 <br /> ame of Local Agency Inspector(f present during testing):Zuna Barker <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Dimaggio Maintenance <br /> Technician Conducting Test:Daniel Noone ICCO0261996 <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A B Haz License Number: 888681 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Franklin Fueling Incon STS 7/25/19 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Diesel Secondary ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ SU 9 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D E DIARTMENT ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ 1 ❑ 1 ❑ 11 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was pumped into trailer storage tank and hauled off site back to the office. <br /> CERTIFICATI OF TECHNICI RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledg h facktat i 1A ument are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:7/12/18 <br />