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�rA SWRCB, January 2002 r *AECEIVED—of Secondary Containment Testing Report FVWd 0 2014 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed%WOMM AAI,I}rlM"es, and printouts from tests (i applicable), should be provided to thefacility owner/operator for subnFEEWISEM401Wulatory agency. 1. FACILITY INFORMATION Facility Name: Estes — Stockton Date of Testing: 3121114 Facility Address: 7611 S. Airport Way Stockton i Facility Contact: Phone: ! Date Local Agcncy Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Pass Fait Technician Conducting Test: Gabe Garcia Repairs Made Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: A License Number: 811471 ICC t# 5281582 Manufacturer Manufacturer Training Component(s) Date Training Expires x ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fait Not Tested Repairs Made Component Pass Fal!Not 'tested Repairs Made Sump 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o a ❑ ❑ ❑ U ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑El❑ IJ ElEl El [1 13--- ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ a 0 - — ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water was filtered and returned to holdin tank, CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements I Technician's Signature'.�� Date: c 4