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Jan 27 16 11:55a JP Petroleum Service 0163724873P.P. <br /> S W RCB,January 2002 Page o f <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 <br /> appropriate pages of this form to report results for all components tested. The completed form. written rest procedures, and <br /> printouts from tests (tf applicable), should be provided to thejacfU4owner/operator for submittal to the local regulatory agencD�. <br /> _ 1. FACILITY INFORMATION <br /> FacHity Name; Country Market Place 1 Date of Testing: 7/14/15 <br /> Facility Address: 1789 W. Charter Way, Stockton Ca <br /> Facility Contact: T1 Phone: 209-535-1096 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION m <br /> Company Name: JP Petroleum Service - <br /> Technician Conducting Test: Gabe Garcia s— <br /> Credentials: x CSLB Licensed Contractor _ L--1W <br /> SRCB Licensed Tank Tester <br /> License Type; A License Number. 81 G#5281582 <br /> Manufacturer Training <br /> FManufacturer Com onent(s) 0a ining Expires <br /> 1•-1�AlT6a r����I7T � r <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular 1 ❑ x ❑ C UDC 1-2 x ❑ ❑ ❑ <br /> Annular 2 x ❑ ❑ C UDC 3-4 x ❑ ❑ ❑ <br /> Sump I x ❑ ❑ ❑ UDC 5-6 ❑ x ❑ ❑ <br /> Sump 2 x ❑ ❑ ❑ UDC 7-8 x ❑ ❑ ❑ <br /> Line 1 ❑ ❑ x ❑ UDC 9-10 <br /> Line 2 ElLlUDC 11-I2 ❑ x ❑ ❑ <br /> X –J <br /> ❑ ❑ x ❑ <br /> Line 3 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 4 x ❑ L ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ C ❑ ❑ ❑ ❑ ❑ <br /> 11 El <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 krtawledge,the-facts stated in this ocument are accurate and in full compUance with legal requirements <br /> Technician's Signature: Date: 7– /L/– <br />