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In <br />SWRCR, January 2002 <br />Page 1 of 7 <br />Secondary Containment Testing Report <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages <br />of this form to report results for all components tested. The completed form, written test proced i from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />LTH <br />1. FACILITY INFORMATION ' Jn i }' r Y E 0 i } ' [: Q <br />C <br />ri�h f 14 CD1?!f <br />Facility Name: San Joaquin Co. Honor Farm <br />I Date of Testin 2.26.03 <br />Facility Address: 7000 N. Michael Canlis Blvd., French Camp, CA 95231 <br />Facility Contact: Earl Gilford <br />Phone: 209.468.3104 <br />Date Local Agency Was Notified of Testing: 12-10-02 <br />Name of Local Agency Inspector (if present during testing) N/A <br />2_ TF,STING CONTRACTOR INFORMATION <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: James Payton <br />Credentials: [X ] CSLB Licensed Contractor [ ] SWRCB Licensed Tank Tester <br />License Type: C -61/D40 HAZ/HIC License Number: 309105 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3_ SIIMMARV OF TEST RF,SIJLTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />DIESEL TANK <br />ANNULAR <br />X <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the faqsstatedlfflhis document are accurate and in full compliance with legal requirements. <br />Technician's Signature: <br />ames Payton <br />0 <br />NOTE: ORIGINAL MAILED -TO: <br />• San Joaquin Co. Environmental Health, Dennis Catenyag <br />• Copy to: San Joaquin Co., Earl Gilford <br />Date: February 26 2003 <br />