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MAR 17 2003 3: 32PM H6LASERJET3200 P. 1 <br /> SWRCR,January 2002 <br /> Page I 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 appropriate pages <br /> of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INTFORMATION <br /> Facili Name: A.G.S anos Jet Center Date of Testing: March 12,2003 <br /> Facility Address: 4800 S.Airport Way,Stockton,CA <br /> FacilityContact: Maureen Brooks Phone: 209.982.155[1 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing)_ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: Eric MoE card <br /> Credentials: (X j CSLB Licensed Contractor [ ] SWRCB Licensud Tank Tester <br /> License Type: C-61111140 HAZ/HIC License Number: 3119105 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Ex fres <br /> _ 3. SUMMARY OF TEST RESULTS <br /> Component Tans Fail Not Repairs Component Pass Irail Not Repairs <br /> _ Tested Made Tested Made <br /> Pi ingRun#1 X Turbine Sump 91 K _ <br /> Piping Run 42 X Turbine SURIP 02 X <br /> Pipi:n&Run 43 X Piping Sum2 41 X <br /> Fi2ing Run#4 X Pi in Siem #2 X <br /> AmnulaF Space#2 X Trans Sump#I X <br /> Annular space 4 1 X X Trans Sump#2 X <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 this do ument are a ate and in frill compliance with legal requirements.. <br /> Technician's signature: c� YhDate: March 12, 2003 <br /> Eric Molgaard <br /> ORIGINAL FAXED TO: Ray Yon Flue,San Joaquin Co.Environmental Health Dept. <br /> Copy Mailed To: Maureen Brooks,A.G.Spanos Jet Center <br />