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K <br /> SWRCB.January 20U2 FINAL DRAFT Page-Lof 2 <br /> Secondary Containment Testing Report .Form <br /> This firm is intendedfor use by contractor,performing periodic kWing of LIST secondarycontainment system.,. (Ise the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printout.,from test,(if applicable),should he provided to the facility owner/operator for submittal to the local regulatory agency, <br /> 1. FACILITY IlYFORMATION <br /> Facility Name; Canepa Car Wash Gate of Testing: 6-30-2003 <br /> Facility Address; 6230 Pacific Avc_,Stockton,CA 95207 1i <br /> Facility Contact; Jeff Canepa Phone: (209)478-5515 <br /> Date Local Agency was Notified of Testing: 6-17-2003_ <br /> Name of Local Agency inspector(if present during testing): Michelle Le <br /> 2. TESTING CONTRACTOR INFO TION <br /> Company Name: 'Thornton&Son Electric <br /> Technician Conducting Test: Brian Thornton <br /> Credentials: ®CS LB Licensed Contractor Q SWRC:B Licensed Tank'rester <br /> I.icense'T'ype; A,C-10,HA9. License Number:724513 <br /> Mina ct_urer Training Manufacturer Component Date Training Expires <br /> Caldwell Sump Level Change indicator One time training <br /> Ronan Leak Monitor 08-01-2003 <br /> Veede'rmRoot Leak Monitor 11-10-2003 <br /> 1NCON Leak Monitor 02.23.2005 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Dail Not Repairs Component Pass Fail Not Repairs <br /> rmttx1 Made Tested Made <br /> Diesel Dispenser Pan 1117 1 0 L1 19 <br /> I El <br /> 13 U Li <br /> ,E'= <br /> Comments-if hydrostatic testing was performed,describe what was done with the water after completion of test(s), <br /> Approximately S.gallons of waste water was disposal of in customers oil/water separator. + <br /> CL'RTIF1CA11ON OF TECHNICIAN RESPONSIBLE FOR CONDUC'T'ING THIS TESTING <br /> 1 o the best of my knowledge,the facts stated in this document are accurate and in full compliance with lepi requirements. <br /> Technician's Name(Please Print): Brian Thornton <br /> Technician's Signature: Date:6-30-2003 <br /> ZO'd 96LO VES 60Z NOS 2 N01NbOH I V99 -'60 EO-OT.-4DO <br />