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SWRCB,January 2002 Page of <br /> Secondi Containment Testing Rep 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 /> 3�0 1. FACILITY INFORMATION <br /> Facility Name: ST Services Date of Testing: <br /> Facility Address: 3105 Navy Drive,Stockton,Ca 95206 bAN j F, J C C'U,-#T Y <br /> r 11 Facility Contact: Dan Miller Phone: KEWL 7 l <br /> Date Local Agency Was Notified of Testing: 12/1/06 <br /> Name of Local Agency Inspector(:f present 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 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <br /> Manufacturer Training <br /> Manufacturer Com ovens Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Line 1 South x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ 1 ❑ 0 ❑ 0 <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El 11 0 El El 0 <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 document are accurate and in full compliance with legal requirements <br /> 1 , <br /> �' Date: Q <br /> Technician's Signature: (/ <br />