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Page 1 of 7 <br /> Secondary Containment Testing Report Form <br /> Stockton Service Station Equipment Co., Inc. <br /> 808 N.Union Street,Stockton,CA 95205(209)4644333 Fax(209)464-8349 California License 309105,A C-61/D40 HAZ <br /> E-MAIL ssseo0@P-acbe1l.net www.stock ronservicestation.com <br /> 1. FACILITY INFORMATION <br /> Facili Name:FAST&EASY CHEVRON <br /> Date of Testing: January 17 2005 <br /> Facili Address:Hw 99 and Ei ht Mile Road,Stockton CA 9521Phone: 1-707-747-2955 <br /> Facili Contact: Pushka <br /> Date Local A enc Was Notified of Testis : <br /> Name of Local A enc Ins color resent durin lestin <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conductin Test: Eric Mol aard and Mike Jones WRCB Licensed tank Tester <br /> Credentials: CSLB Licensed Contractor ] SLicense Number: 309105 <br /> License T C-61l MU IL&UHIC <br /> Manufacturer Trainirla Date Tra sin E ices <br /> Manufacnner Co onen s N/A <br /> Western Fiberglass,Inc. stems <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Paso Fail Tsted <br /> ° Repairs <br /> Tested Made <br /> 89 Octane S ill Bucket <br /> X X <br /> If hydrostatic testia&was performed,describe what was done with the water after completion of teaL9: <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 hest of my la uw'Icdg4 the fam stated in this document are accurate and in full compliance with legal requircments. <br /> Technician's Signature: Eric .'MO yr nd aneg <br /> Date: January 17,2005 <br /> Eric Molgeard and Mike Jones <br /> Original mailed to: San Joaquin County Environmental Health Division <br /> I -d 002E 13Cd3SH-1 dH WdOT :E 2002 02 WHC <br />