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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 of thisform 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: ST Services Date of Testing: 2/3/06 <br /> Facility Address: 3105 Navy Drive, Stockton Ca 95206 <br /> Facility Contact: Dan Phone: <br /> Date Local Agency Was Notified of Testing : 1/20/06 <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: John Puumala <br /> Credentials: x CSLB Licensed Contractor 0 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 /> Line 1 South ❑ x 0 ❑ 0 ❑ ❑ ❑ <br /> Line 2 North x ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> Sump 1 x 1 0 ❑ ❑ ❑ O ❑ ❑ <br /> Annualr 1 x 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D D ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ 0 0 11ElEl0 ❑ El 11 ❑ El11 <br /> El El 11 1E]❑ ❑ ❑ <br /> If hydrostatic te6ting 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 /> Technician's Signal Date: <br />