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SWRCR,January 2002 <br /> Page 1 of 7 <br /> D <br /> Secondary Containment Testing Repoff <br /> Stockton Service Station Equipment Co., IN@ V 10 2004 <br /> ENVIRON <br /> 808 N. Union Street, Stockton, CA 95205-4152 (209) 464-8333 FTftMINAA49 <br /> California Contractor License 309105 A-C61/D40 HAZ/HIC E-mail ssseconpa <br /> 1. FACILITY INFORMATION <br /> Facility Name: Beacon Food Shop Date of Testing: October 27,2004 <br /> Facility Address:2185 E.Fremont Street,Stockton,CA 95205 <br /> Facility Contact: Lal Phone: 209.937.0195 <br /> Date Local Agency Was Notified of Testing: October 21,2004 Confirmed 10.26.04 <br /> Name of Local Agency Inspector(if present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: Eric Mol aard <br /> Credentials: IX 1 CSLB Licensed Contractor [ SWRCB Licensed Tank Tester <br /> License Type: C-61/D40 HAZ/HIC License Number: 309105 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Smith Fiberglass Products Company 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 /> Tank Annular Testing,Page 2 X <br /> Secondary Pipe Testing,Page 3 X <br /> Piping Sump Testing,Page 4 X <br /> UDC,Testing,Page 5 X <br /> Spill/Overfill Containment,Page 7 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> (Pages 6 N/A) <br /> Five drums left on site for removal by a certified waste hauler. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING 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: Date: October 27,2004 <br /> Eric Molgaard <br /> COPIES TO: San Joaquin County Environmental Health District <br /> Mr. Lal with Beacon Food Shop <br />