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1 0 *RECEIVED <br />S W RCB, January 2002 Page _1_ of _8_ <br />Secondary Containment Testing Report Form OCT 19 2016 <br />This form is intended for use by contractors performing periodic testing of UST secondary c t LTH <br />appropriate pages of this form to report results for all components tested. The completed fo c <br />printouts from tests Cf applicable), should be provided to the facility owner/operator for submittal to agency. <br />1. FACILITY INFORMATION <br />Facility Name: UNITED #5446 1 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: 9127116 <br />Name of Local Agency Inspector (ifpresent 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 9115/2018 <br />3. SUMMARY OF TEST RESULTS <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: 1016 18 <br />PRODUCT SECONDARY <br />87 FILL BUCKET <br />033 <br />on <br />M <br />M <br />-DIESEL <br />DIESEL STP SUMP <br />Ila <br />87 VAPOR BUCKET <br />87 - - <br />ao=+=� <br />-� - = <br />-Elm <br />DIESEL FILL BUCKET <br />130MM'DIESEL <br />VAPOR BUCKET <br />WASTE OIL FILL BUCKET <br />.. <br />/, <br />a�r�■ <br />0000 <br />LWASTE <br />ILI 11-1-19 . --.. <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: 1016 18 <br />