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SWRC , Januury 2002 <br /> Parr <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 /> Cali fomia Coritracior Liccue 309105 A-C6IID40 RAZ(HIC E.mallsssrcue ebell.net <br /> 1. FACILITY INFORMATION <br /> FaciR Nillllc <br /> Facility Address: Dace of Testi <br /> Facility Contact: <br /> -Date Local Arne- Was <br /> Nutiiic� <br /> ! Name of Local Agency Inspector(if Prosent durin,tcv — <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com any Name; Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: <br /> Credrn[ials; (X ) CSLB Licensed Contractor r 4 —._. <br /> Licrn�pc: C•61ID40 1-1AZ✓h IC 3Wf�C13 Lice used Tarek Triter _ <br /> Licrnse Number; 309105 <br /> Manufacturer Manufacturer Trainhi <br /> Com onent s <br /> Smith Pibrr lass Products Coin an Date Trainin Ex iris <br /> N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> ^� Comp rima Paas Fall Not Rcpalna Cotu uAant �—r— <br /> •Ceded Made R Pass Foil C1'ue kvi. <br /> IeseerJ i A1: <br /> �It hydrostatic testing was performed,describe wtaat was done with the waster sifter oontpletion of tests; <br /> CER•t•IF•ICA r10N OF I•ECHNICIAN RB3PONSIBLE FOR CONDt1CTING THIS TESTING <br /> i'u die best of my knowledge, the facts stated in this do men[are accurate and in full complianoC with legsl requirrmrnts <br /> t <br /> '1'edu[ cian's Signature; <br /> Date: <br /> I <br />