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UE -C 2 3 20OZ <br />SWRCR, January 2002 4-_NLT <br />FLiiiV:a l,SERVICES Page 1 of <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 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 />1. FACILITY INFORMATION <br />Facility Name: SAN JOAQUIN COUNTY, HONOR FARM Date of Testing: 12/17/02 <br />Facility Address: 7000 N. Michael Canlis Blvd., French Camp, CA <br />Facility Contact: Earl Gilford Phone: 209.468.3104 <br />Date Local Agency Was Notified of Testing: 12.10.2002 <br />Name of Local Agency Inspector if present during testing) N/A <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: James Payton <br />Credentials: Ix I CSLB Licensed Contractor I I 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. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />Unlead Tank Annular <br />X <br />Diesel Tank Annular <br />X <br />Unlead Secondary Product Pipe <br />X <br />Unlead Secondary Vapor Pipe <br />X <br />Diesel Secondary Pipe <br />X <br />Unlead Sump <br />X <br />Diesel Sump <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER WAS LEFT ON SITE TO BE RE -USED FOR RE -TEST AFTER REPAIRS. <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: December 17d', 2002 <br />ORIGINAL MAILED TO: <br />San Joaquin County <br />Environmental Health Div. <br />Attn: Dennis Catenyag <br />304 E. Weber St., 3`d Floor <br />Stockton, CA 95202 <br />