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M, 22/2003 11:39 77535""-11 LA PERKS PAGE 05 <br />Secondary Containment Vesting Report Form Page t of 2 <br />This form Is intended for use by contractors performing periodic testing of UST secondary contah merit <br />pages o this orm to re systems. Use the appropriate <br />1r } porn results for all components testes: The completed form, written test procedures, and printouts from tests q <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I. FA INFO TION <br />FacilityName: Quik Stop#124 San Jo uin Compalhate of Testing: S/15/03 <br />Facili Address: 505 No. Main St. Mantes CA 95336 <br />Facili Contact: A.R. & Sons Co Phone: 209823-7628 <br />Coun Contact: Foley, Fhone:209-468-3451 <br />Date Local A enc Was Notified of Testing: <br />Name of Local Aeencv Inmecter Pr ,nr• <br />2. TESTING CONTRACTOR INFO TION <br />Cana an Name: L.A.Perks Plumb' & He Inc, <br />Technician Cond ;ON Test: Keith Perks <br />Credentials: X CSL$ Licensed Contractor o SWRCB Licensed Tank Tester <br />License Type and #: A, C-36, HAZ 0678948 <br />Training by Manufacturer <br />J. SAW-U-11AX OF TEST RESULTS <br />W"M Number of Pi In Runs Tested: 0 <br />Neu MOO <br />►� �' Rig ��- ♦' ��• 1 <br />Number M . :,� t <br />compkippt, <br />• ' Aaced with New OPW lid <br />Technician's Signauue: <br />SWRCB <br />Page 2 of 2 <br />