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I <br /> • S W RCB,January 2002 Page I of 2- <br /> Secondary <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 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. FACILITY INFORMATION <br /> Facility Name: PG&E I Date of Testing:,.,,.. ,Q/22/al 7 <br /> Facility Address: 4040 West Lane, Stockton,CA 95204 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: MAR 2 7 <br /> Name of Local Agency Inspector(f present during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION PEIWITrSER°.t ,ES <br /> Company Name: Central Petroleum Maintenance <br /> Technician Conducting Test: Gregg Geltz <br /> Credentials: X CSLB Licensed Contractor _ ❑ SWR_CB Licensed Tank Tester <br /> License Type: C61 /D40 License Number: 491948 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Used oil pipe X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 11 ❑ 11 11 11 <br /> ❑ ElEl El ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of nay knowledge,the facts stated in this document are accurate and in./ull compliance with legal requirements <br /> Technician's Signature: Date: <br />