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SWRCB,January 2002 */ Page_of_ <br /> Secondary Containment Testing Report Form 1 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systeF. Whe <br /> appropriate pages of this form to report results for all components tested The completed form, written teg lcedu and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the(c�ye$ula i�r agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Fast&East Mart Date of Testing: <br /> , <br /> Facility Address: 244 West Harding Way,Stockton Ca 95204ti o <br /> Facility Contact: Indejit Phone: 209-948-8001 7 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: Gabriel Garcia <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <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 /> Sump#1 Regular x ❑ ❑ x ❑ ❑ ❑ ❑ <br /> Sump#2 Supreme x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line#1 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line#2 Supreme x ❑ ❑ x ❑ ❑ ❑ ❑ <br /> UDC 1&2 x ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> UDC 3&4 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ L,❑ ❑ ❑ 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 knowledge,the facts stated in this docu7"t are accurate and in full compliance with legal requirements <br /> Technician's Signature: vert/ _ycyG e ? Date: /J—7- US <br /> cJ0.ri �v%,n EA1 <br />