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SWRCB,January 2002 Page_of_ <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 ofthis form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACrLLrrY INFORMATION <br /> Facility Name: Arch Road AMIPM Date of Testing: 6-9-11 <br /> Facility Address: 4855 South Highway 99 Stockton Ca <br /> Facility Contact: Sunny Phone: 408-806 9148 <br /> Date Local Agency Was Notified of Testing:6-6-11 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: Gabe Garcia <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5281582 <br /> Manufacturer Training Manufacturer Com onen s Date`I'rainin E fires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass pad Tested Made Component Pass Fail Tested Made <br /> Annular 1 x ❑ ❑ ❑ UDC 1+2 x ❑ ❑ CI <br /> Annular 2 x ❑ ❑ ❑ UDC 3+4 x ❑ ❑ <br /> Annular 3 x ❑ 11 ❑ UDC 5+6 ❑ x ❑ F1 <br /> ❑ ❑ ❑ ❑ UDC 7+8 x ❑ ❑ ❑ <br /> Pipe Run 1 x ❑ ❑ ❑ UDC 9+10 x ❑ ❑ 1 ❑ <br /> Pipe Rum 2 x ❑ ❑ ❑ UDC 11+12 x ❑ ❑ 1 ❑ <br /> Pipe Run 3 x ❑ ❑ ❑ UDC 13+14 x ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ UDC 15+16 x ❑ ❑ ❑ <br /> Su inp I x ❑ ❑ ❑ UDC 17+18 ❑ x ❑ ❑ <br /> Sump 2 <br /> x ❑ ❑ ❑ Cl ❑ ❑ ❑ <br /> Sump3 x ❑ In ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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,the facts stated in this ocument are ac�urraaiee and in full compliance with legal <br /> 1requirements <br /> Technician's Signature: ei4G?�% Date: 1 l <br />