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yr <br />SWRCB, January 2002 Page I of Q <br />Secondary Containment Testing Report Form <br />This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use tl e <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:rc-)rja-va-rd Date of Testing: <br />Facility Address: 1810 E <br />. Hazelton Street., Stoc ton, CA 95209 <br />Facility Contact: Earl CilfnrdPhone: _ —,in gg <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: <br />wm�= <br />Technician Conducting Test: Payton <br />Credentials:-' SLB Licensed Contractor ❑ SWRCB Licensed Tank TesterCD <br />License Type:3 0 91 05 A C61/Q40 HA Z H I C <br />License Number: <br />o <br />Manufacturer Trainine <br />Manufacturer Component(s) <br />Date Trai4pp, <br />0 �. <br />Ex t8s <br />Annular Unl-.. <br />000 <br />r <br />.00 <br />r- <br />3. SUMMARY OF TEST RESULTS <br />Component <br />wm�= <br />Annul a Diesel <br />Annular Unl-.. <br />000 <br />Unlead Pioe Vuj. <br />- - . . - ----m <br />Sump STP - ..lie <br />:UDC 1 - .. <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT AT SITE IN BARRELS HAD THEM HAITI E -h By A 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 />a <br />Technician's Signature: Date: , <br />Original Mailed To: <br />San Joaquin County Environmental Health Div. <br />Attn: Ray Von Flue <br />304 E. Weber Ave., 3`d Floor <br />Stockton, CA 95202 <br />