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SW.RCB, January 2002 <br />-oort Form <br />Page _._— of <br />r ' <br />Tltis form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this forts 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 jor submittal to the local regulatory agency. <br />Is U A r3r VrV t NIVAID X4 ®'rlFAN <br />1~acilq Name: Bank of Stockton Date of Testing: 6-27-12 <br />Facility Address: 1941 R Lockheed. Court, Stockton Ca <br />:facility Contact: Norm. Phone: 209-483-0257 <br />Date Local Agency Was Notified of Testing: _.. <br />Name of Local Agency Inspector (f present during testing): <br />i. •. c_ a. . •=►r= 1110 <br />Company Name: JP Petroleum Service <br />Technician Conducting Test: Gabe Garcia <br />Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A License Number: 811471 ICC # 5281582 <br />Manufacturer Training <br />Date Traini <br />I 174 kvi F -AIN 0A I I A V M I HT&I <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular I <br />7i <br />❑ <br />_ <br />(] <br />(l <br />❑ <br />1.1 <br />0 <br />Line 1 <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />F1 <br />❑ <br />1_1 <br />Line 2 <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />i] <br />1.1 <br />Line 3 <br />x <br />1 ❑ <br />71 <br />17 <br />❑ <br />❑ <br />❑ <br />❑ <br />Sump 1 <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />sump 2 <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Spill Bucket <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />Fj <br />❑ <br />F <br />,1 �� <br />n <br />n <br />(_:; <br />n <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />c <br />c:� <br />11 <br />El <br />❑ <br />❑ <br />❑ <br />c] <br />❑ <br />❑ <br />( <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El❑ <br />ff <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water was filtered and returned to holding tank. <br />CERTIFICATION GF TECUNICIA.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the fac stet d in this decu enI urate and in full compliance with legal requirements <br />Technician's Signature: s �� Date: V `" "'- <br />