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0 <br />SW RCB, January 2002 FINAL DRAFT <br />Secondary Containment Testing Report Form <br />Page 1 of 7 <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: Super Stop Gas & Food Date of Testing: 12-29-2002 <br />Facility Address: 515 West I Ph Street Tracy, CA 95376 <br />Facility Contact: Sema Sharma Phone: (209) 839-9022 <br />Date Local Agency was Notified of Testing: 12-22-2002 <br />Name of Local Agency Inspector (if present during testing): <br />Company Name: <br />Thornton & Son Electric <br />Technician Conducting Test: Brian Thornton <br />Credentials: <br />® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, C-10, HAZ License Number: 724513 <br />Manufacturer Training <br />Manufacturer Component <br />Date Training Expires <br />Veeder-Root <br />Leak Monitor <br />10-10-2003 <br />Ronan <br />Leak Monitor <br />07-30-2003 <br />Incon <br />Leak Monitor <br />01-28-2003 <br />Caldwell <br />Sump Level Change Indicator <br />One time training <br />3. SUMMARY OF TEST RESULTS <br />Comments — If hydrostatic testing was performed, describe what was done with the water after completion of test(s). <br />Approximately 100 gallons waste water was left on site in (2) labeled 55 gallon drums for customer to dispose of. <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 Name (Please Print): Brian Thornton <br />Technician's Signature: s Date: 12-29-2002 <br />