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SWRCB, January 2002 Page _I_ of _8_ <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 (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: UNITED #5446 Date of Testing: 1016116 <br />Facility Address: 1403 COUNTRY CLUB BLVD, STOCKTON, CA 95204 <br />Facility Contact: ALLEN FAASS I Phone: (949) 289-5286 <br />Date Local Agency Was Notified of Testing: 9/27116 <br />Name of Local Agency Inspector (fpresent during testing): NONE PRESENT <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORPORATION <br />Technician Conducting Test: ROBERT SLUNAKER <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A License Number: 803705 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN #8041107 7/14/2018 <br />FRANKLIN FUELING INCON SUMP TESTER #1009833708 9/15/2018 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not Repairs <br />Tested Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />DIESEL PRODUCT SECONDARY <br />® <br />❑ <br />❑ ❑ <br />87 FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />DIESEL STP SUMP <br />® <br />❑ <br />❑ ® <br />87 VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />87 PRODUCT SECONDARY <br />® <br />❑ <br />❑ ❑ <br />1 91 FILLBUCKET <br />® <br />❑ <br />❑ <br />❑ <br />87 STP SUMP <br />❑ <br />❑ <br />® ® <br />91 VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />91 PRODUCT SECONDARY <br />® <br />❑ <br />❑ ® <br />DIESEL FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />91 STP SUMP <br />® <br />❑ <br />❑ ® <br />DIESEL VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />UDC #1/2 <br />® <br />❑ <br />❑ ❑ <br />WASTE OIL FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />UDC #3/4 <br />® <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC #5/6 <br />® <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC #7l8 <br />® <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />WASTE OIL FILL/PIPE SUMP <br />® <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />WASTE OIL PRODUCT SEC <br />® <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <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: --� Date:1116 6 <br />