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MOVED <br /> Secondary Containment Testing Report Form .IAN 1 4 M09 <br /> Stockton Service Station Equipment Co., Inc. ENVIIR�O�N17M�EENNT HEALTH <br /> 808 N.Union Street,Stockton,CA 95205(209)464-8333 Fax(209)464-8349 California License 309105,A C=bT/DaUs <br /> E-MAIL ssseco(apacbell.net www.stocktonservicestation.com <br /> 1. FACILITY INFORMATION <br /> Facility Name:FAST&EASY CHEVRON I Date of Testing: January 17,2005 <br /> Facility Address:Hwy 99 and Light Mile Road,Stockton,CA 95212 <br /> Facility Contact: Pushka I Phone: 1-707-747-2955 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector(if resent during testin ): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: Eric Mol card and Mike Jones <br /> Credentials: [XI CSLB Licensed Contractor I I SWRCB Licensed tank Tester <br /> License Type: C-61/D40 HAZ/HIC License Number: 309105 <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Trainin Ex fres <br /> Western Fiberglass, Inc. Piping/Sump Systems N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 89 Octane,Spill Bucket X X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PAGES 2, 3,4, 5, 6, are not applicable. <br /> NOTE: REPLACED DRAIN VALVE AND TESTED. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTION THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements. <br /> Technician's Signature: Eric No(gaardandmike Tones Date: January 17,2005 <br /> Eric Molgaard and Mike Jones <br /> Original mailed to: San Joaquin County Environmental Hcalth Division <br />