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1 9 0 <br />SWRCB, January 2002 <br />Page t of <br />Secondary Containment Vesting Report Form <br />This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of'this forea to report results for all components rested The completed foam, written test procedures, and <br />printouts from tests (if applicable), staould he provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Stockton AASF Date of Testing: 12111/02 & 5/14/03 <br />Facility Address: 2WOStimson Road, Stockton CA 95206 <br />Facility Contact: SFC CurtLance Phone: 2099$3.5331 <br />Bate I.ocal Agency Was Notified of Tealing : 5/8/03 <br />Name of Local Agency Insr=tor (rf present during testing): On 12/11/03 2 men <br />2. 'TESTING CONTRACTOR INFORMATION <br />Company Name: (ventral Coast Tank Testing <br />--- <br />Technician Conducting Test: Robert Hankenson <br />Credentials: ❑ CSLB Licc nscd Contractor <br />X SWRCS Licensed Tank Tester <br />License Tj rpc: <br />Lige Number: CA 91-1169 <br />]Manufacturer <br />Manufacturer <br />Training <br />Component(s) Date Training F.xires <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was pe4onned, 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 knowle4e, the facts &aced in this document are accurate and its full conydiance wink legal requirements <br />Technician's Signature: <br />Date: C� An -02) <br />2'd OBBOLBSSOB ux4sal Muel -.seoO jeJ4uao d001E0 ED ST Rew <br />T 4115K annular 12/11/02 <br />T #10 spill <br />T 41 Issue Line 5114103 <br />T#2 Reel line .,oaoo <br />aaror� <br />If hydrostatic testing was pe4onned, 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 knowle4e, the facts &aced in this document are accurate and its full conydiance wink legal requirements <br />Technician's Signature: <br />Date: C� An -02) <br />2'd OBBOLBSSOB ux4sal Muel -.seoO jeJ4uao d001E0 ED ST Rew <br />