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r, <br />C <br />7 0 0 <br />-SWRCR, January 2002 <br />Page I 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 />Facility Name: San Joaquin Co. Honor Farm <br />Date of Testing: 2-11-03 <br />Facility Address: 7000 N. Michael Canlis Blvd., French Camp, CA <br />Facility Contact: Earl Gilford <br />Phone: 209-468-3099 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency inspector (if present during testing) Dennis Catera a <br />Com an Name: Stockton Service Station Equi ment Co., Inc. <br />Technician Conducting Test: Eric Mol acrd <br />Credentials: IX I CSLB Licensed Contractor L 1 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 />Component <br />Pas <br />s <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 />UNLEAD GAS SUMP <br />X <br />X <br />DIESEL FUEL SUMP <br />X <br />X <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />WATER WAS LEFT ON SITE IN DRUM FOR REMOVAL BY CERTIFIED WASTE HAULER <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are curate and in full compliance with legal requirements. <br />Technician's Signature: Date: February 11, 2003 <br />Eric Molgaard <br />NOTE: ORIGINAL MAILED TO: <br />• San Joaquin County Environmental Health Division <br />Copy to: <br />• San Joaquin County, Mr. Earl Gilford, Motor Pool <br />