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SWRCB, January 2002 Page _1_ of _2_ <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1_ FACTT.TTV INFORMATION <br />Facility Name: CRLLC #5446 Date of Testing: 91212011 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing: 811812011 <br />Name of Local Agency Inspector (f present during testing): NONE PRESENT <br />I TF.CTTNf_' CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />• ' 1 <br />Technician Conducting Test: <br />RICHARD THOMAS <br />• - • • • . • - <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />0�� <br />License Type: <br />Manufacturer <br />A (CSLB Lie) License Number: 803705 (CSLB Lic) -- 06-1672 (SWRCB Lic.) <br />Manufacturer Training <br />Component(s) Date Training Expires <br />ICC <br />CA UST SERVICE TECHNICIAN #5254736 -UT <br />DEC 28, 2012 <br />SCWRCB <br />TANK TESTER LICENSE #06-1672 <br />JUN 30, 2012 <br />FRANKLIN FUELING <br />INCON SUMP TESTER #5012133701 <br />FEB 8, 2013 <br />ODO� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: � - L U� Date: 9/2/2011 <br />• ' 1 <br />'7 FIEV 1 <br />• - • • • . • - <br />► <br />0�� <br />0000 <br />ODO� <br />ODO� <br />ODO� <br />OOOD <br />ODO� <br />OOO�� <br />ODO� <br />0000 <br />a000 <br />oaoo', <br />0000 <br />0000 <br />�000 <br />0000 <br />.. <br />0000 <br />0000 <br />0000 <br />0000' <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: � - L U� Date: 9/2/2011 <br />