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07/25/2003 10:15 7753584411 LA PERKS PAGE 02 <br />Secondary Containment Testing Report Form <br />Page t of 3 <br />This form is intended for use by co►tri ac7ors Per periodic testing of UST secondary containment systems, Use the appropriate <br />pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (if <br />appl►cable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />l,. FACUJTY INFORMATION <br />Facility Name: Loves Travel Stop 233 San Joaquin) Date of Testis . 7/17/03 <br />Facility Address: 1553 Colony Road Ri on, CA 95366 <br />Facili Contact: Phone: 209-599-0740 <br />Caen Contact: Kace Fole Phone: 209-468-3451 <br />Date Local A qncy Was Notified of Testis I. <br />Name of Local Agency I ctor Present: <br />2. TESTING CONTRACTOR INFORMATION <br />Comp ny Name: L.A.Perks Plumbing & Heating Inc. <br />Technician Conductin 'fest: <br />Credentials: X CSLB Licensed Contractor o SWRCB Licensed Tank Tester <br />License Type and #: A, C-36, HAZ 0678948 <br />Training by Manufacturer <br />Manufactercer Corn ents s <br />OPW <br />Technician's Signature: <br />SWRCB <br />Date: ___ . 7/17/03 <br />3. SUMMARY OF TEST RESULTS <br />Number of Tanks Tested: 0 <br />Number of Piping Runs Tested:0 <br />Number of Submersible Pump <br />Sum <br />s Tested:0 Number of LDDC Boxes Tested:0 <br />Number of Fill Sum s Tested:0 <br />Number of Overfill Boxes Tested:5 <br />Component Pass <br />Fail <br />Comments <br />Diesel fill #1 X <br />❑ <br />Diesel fill #2 X <br />❑ <br />87 fill #1 X <br />Q <br />87 fill #2 X <br />a <br />9I fill X <br />❑ <br />a <br />❑ <br />o <br />n <br />a <br />❑ <br />a <br />❑ <br />❑ <br />a <br />❑ <br />a <br />a <br />❑ <br />❑ <br />❑ <br />Technician's Signature: <br />SWRCB <br />Date: ___ . 7/17/03 <br />