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R RECENED 1* 0 SWRCB, January 2002 Page of 200 econdary Containment Testing Report Form %I Mqeso ELTf This or e y contractors performing periodic testing of UST secondary containment systems. Use the appropriate pa is Orin to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: ,S'TOC K OIJ 4A&r I Date of Testing: 12 / os Facility Address: 7000 Sit tm S o/4 R 0 XT -0 c Krog C A .. 9S2 0 61 Facility Contact: 5 FCC_ p,ty-raUe O pl'Ci, Phone: ( 7-oc%) g 83 —S33 1 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: -rA M K T'€ A" N C Technician Conducting Test: lajECTcR pU*I,ob Credentials: I,CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: C t4G A e. t o 1 L S-7 License Number: S I Z €3 3 5 Manufacturer Training Manufacturer Component(s) Date Training Expires �%Ri►+.rklieJCs FOCI, SYsTE,&A a:"Co" itI°alofo 3. SUMMARY Component Pass OF Fail Not Tested TEST RESULTS Repairs Component Pass Fail Not Repairs Made Tested Made "� AW1C ANS 14 ❑ 0 0 ❑ ❑ ❑ ❑ SECO&JOWL L f"C 1 IX ❑ 0 ❑ 0 0 ❑ ❑ SCLONJO pnY L%Mc L (K ❑ ❑ ❑ ❑ ❑ ❑ 0 SUMP (X ❑ ❑ ❑ ❑ ❑ ❑ ❑ U®L 1 l& ❑ 0 ❑ ❑ ❑ ❑ ❑ 4LZ It 0 ❑ ❑ ❑ ❑ ❑ ❑ 51?t1,.L Sox ❑ o ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 ❑ ❑ 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 ❑ ❑ ❑ 0 ❑ 0 0 0 ❑ ❑ 0 0 ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: WwvE(z PuT en1 t3%%- wV%TCrc SCPAa^,MiL _ CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: �Date: 12' 8to )