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f yt <br /> C—vVRCB jaftuary,2002 .fob#: 029132 ]Page of <br /> Secondary Containment Testing Report Form Customer <br /> - This form is intended for use by contractors performing periodic testing of USI secondary containment systems. Use the <br /> ppropriate pages of this farm to report results for all components tested. The completed form,written test procedures, and <br /> rintouts from tests(if applicable), should be provided fo the facility owner/operator for submittal io the local regulatory agency <br /> Facility Name: Stockton,CA Switch Date of Testing: 10/28/2005 <br /> Facility Address: 3807 Coronado Ave Stockton CA 95204 <br /> Facility Contact: Ron Williams Phone: 209-937-5800 <br /> Date Local Agency Was Notified of Testing: 1012612005 <br /> Name of Local Agency Inspector (if present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Shirley Environmental Testing <br /> Technician Conducting Test: Robert Soto <br /> Credentials: p CSLB Licensed Contractor p SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Training <br /> Manufacturer Com rlent(s) Date Training E- ices <br /> Incon TS-STS <br /> Pressure with a 4"gauge <br /> 3. SUMMARY OF TEST RESULTS <br /> + preI Not Repairs Not Repairs <br /> Component Pass Fact Tested Made Component Pass Fait Tested Made <br /> SL STP ❑ El 0 0 <br /> SL pill Bucket ® ❑ ❑ 11 ❑ 0 0 0 <br /> etum Secondary ® 0 <br /> apply Secondary <br /> ank Ann Wet D El <br /> Li U Li <br /> Yf hydrostatic testing was perforated.describe-what was done with the eater after corupletion of tests: <br /> Pui in ss(jai orurns <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of M,knowledge,the facts stater]in this document are accurate and in full compliance with legal requircmunts <br /> Technician Name(print): Robert Soto <br /> Technician's Signature: Date: 1012812005 <br /> ` Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary containment,such a <br /> cmc+umc+ham+a+e —.— -PWPTY +f--—.,4-A;-rnntn.nrr.on++—+inn !'-A.of <br />