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JUL 2 8 2014 ENViRON�M,ENTA,� HEALTH SWRCF3,Januat'y2002 OEPA ENT- Secondary Containment Testing Report Form This form is brtended fa, use by contractors perfot•iiiing periodic testing of UST secondary contaiwitent systetirs. Use the appropriate pages of thisforin to repos results for all components tested The completedform, written test procedures, and printouts from tests ({f applicable), should be provided to the facility owtaer/operator• for siibntirtal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: LOVE"S 223 Date of'I'esting: 6/16/14 Facility Address: 1553 COLONY RD I COUNTY I SAN JOAQUIN Facility Contact: NEIL Phone: 209-559-0740 Date Local Agency Was Notified of Testing: County Contact: Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: L,A. Perks Plumbing & Heating Inc. Technician Conducting Test: hail Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester _ License Type: A, C-36, HAL License Number: 678948 Manufacturer Component(s) BRAVO FIBERGLASS SUMPS NOV / SMITH PIPING ❑ SECONDARY MAIN X ❑ 3. SUMMARY OF TEST RESULTS Component Pass hail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made DISP 25 X ❑ ❑ ❑ SECONDARY MAIN X ❑ ❑ ❑ DISP 26 X ❑ ❑ ❑ SECONDARY SAT X ❑ ❑ El DISP 27 X ❑ ❑ ❑ SECONDARY SAT X ❑ ❑ ❑ DISP 27S X ❑ ❑ ❑ SECONDARY X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _ ❑ 10 ❑ ❑ ❑ ❑ ❑ ❑ -- ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ - ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water aper completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my lutowledge, the facts stated in this docznueid are aeenrate and lit Rill compliance with legal regtih-entents Technician's Signature: RON WOOD Date:___6/16/14