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0 <br /> *%uWRCR,January 2002 9 ' <br /> Page 1 of 7 <br /> Secondary Containment Testing Report Form <br /> Stockton Service Station Equipment Co., Inc. <br /> 808 N. Union Street, Stockton, CA 95205-4152 (209) 464-8333 FAX (209) 464-8349 <br /> California Contractor License 309105 A-C61/D40 HAZ/HIC E-mail ssseco n,pacbell.net <br /> 1. FACILITY INFORMATION <br /> Facility Name: Bank of Stockton Date of Testing: June 17,2009 <br /> Facility Address: 1941 E.Lockheed Court,Stockton,CA <br /> Facility Contact: Norm White Phone: 209.483.0257 <br /> Date Local Agency Was Notified of Testing: May 28,2009 <br /> Name of Local Agency Inspector(if present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION_ <br /> Company Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: Mike Jones <br /> Credentials: [X] CSLB Licensed Contractor [ ) SWRCB Licensed Tank Tester <br /> License Type: C-61/D40 HAVRIC License Number: 309105 <br /> Manufacturer Trainin>r <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular Testing X <br /> Secondary Pipe Testing,VENT Fail X <br /> Piping Sump Testing X <br /> Spill/Overfill Containment Boxes X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PAGE 5 & 6 N/A <br /> Secondary Pipe Vent Failed <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: alike-Tones Date: June 17,2009 <br />