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January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of 7 <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 procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator.for submittal to the local regulatory agency. <br />481041W M#k <br />Facility Name: San Joaquin Co. Honor Farm <br />Date of Testing: 2.26.03 <br />Facility Address: 7000 N. Michael Canlis Blvd., French Camp, CA 95231 <br />Facility Contact: Earl Gilford <br />Phone: 20 P 1 �4 <br />Date Local Agency Was Notified of Testing: 12-10-02 l <br />Name of Local Agency Inspector (if present during testing) N/A <br />2. TESTING CONTRACTOR INFORMATION 3003 <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />ENVIRONJ H'Ei'A'Cl h <br />Technician Conducting Test: James PaytonPJ.,.f <br />p /. - R ,, 1 l; <br />Credentials: X I CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: C -61/D40 HAZ/HIC <br />License Number: 309105 <br />Manufacturer Training <br />f Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <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 />i <br />it nyarostatic testing was pertormea, 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 fact�s>atetfi� document are accurate and in full compliance with legal requirements. <br />Technician's Signature: <br />Payton <br />NOTE: ORIGINAL MAILED -TO: <br />• San Joaquin Co. Environmental Health, Dennis Catenyag <br />• Copy to: San Joaquin Co., Earl Gilford <br />Dater February 26 2003 <br />