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SWRCB, January 2002 Page I of <br />Secondary Containment Testing Report Form <br />This form is intendedfor use by contractors petforming periodic testing of UST secondaly 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: Stockton AASF I Date of Testing: 12/11/02 & 5/14/03 <br />Facility Address: 2000Stimson Road, Stockton CA 95206 <br />Facility Contact: SFC Curt Lance Phone: 209983.5331 <br />Date Local Agency Was Notified of Testing: 5/8/03 <br />Name of Local Agency Inspector (if present during testing): On 12/11/03 2 men <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Central Coast Tank Testing <br />Technician Conducting Test: Robert Hankenson <br />Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: License Number: CA 91-1169 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3 SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 Signature: Date: ' \5• �3 <br />F; FA(4 =1c Y`s`' <br />oaoo <br />0000, <br />0000 <br />a©oo <br />DDO� <br />DOO�I <br />r <br />DOOO <br />ODO�' <br />Transition5/14/03 <br />oaoo <br />0000 <br />0000 <br />aaaoo <br />.1 UDC 5/14/030000 <br />0000 <br />0000 <br />oa��■ <br />0000 <br />000■a <br />.. ' , <br />oaoo <br />a000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 Signature: Date: ' \5• �3 <br />F; FA(4 =1c Y`s`' <br />