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SWRCB,January 2002 `of .aw Page of <br /> Secondary Containment Testing Report Form <br /> Thu form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: BJJ Trucking I Date o-- - /9/05 <br /> Facility Address: 2431 E.Mariposa Road, Stockton Ca 95205 <br /> Facility Contact: Nick or Dave Phone: 209-941-2576 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(i(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <br /> Manufacturer Trainint! <br /> Manufacturer Component(s) Date Train;- Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> Annular 1 x ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> Annular 2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 1 x ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> Line 2 x ❑ ❑ 0 0 ❑ 0 ❑ <br /> Sump 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 2 x ❑ ❑ ❑ ❑ ❑ 1flE <br /> UDC 1&2 x 0 0 ❑ ❑ 0 <br /> UDC 3&4 x 0 ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Date: <br /> V <br />