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SWRCR, January 2002 <br />Page 1 of 7 <br />Secondary Containment Testing Report Form <br />Stockton Service Station Equipment Co., Inc. <br />808 N. Union Street, Stockton, CA 95205-4152 (209) 464-8333 FAX (209) 464-8349 <br />California Contractor License 309105 A -C61/1340 HAZ/HIC E-mail ssseco &pacbell.net <br />Facility Name: San Joaquin County, General Services Date of Testing: December 2, 2005 <br />Facility Address: 7000 N. Michael Canlis Blvd., French Camp, CA <br />Facility Contact: Tom Valtierra Phone: 209.468.4637 <br />Date Local Agency Was Notified of Testing: 12/01/2005 <br />Name of Local Agency Inspector (if present during testin ) <br />TFCTrlerr_ rnNTRArTnR INFnRMATInN <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Russell Chadwick <br />Credentials: [X ] CSLB Licensed Contractor [ ] SWRCB Licensed Tank Tester <br />License Type: C -61/D40 HAZIHIC License Number: 309105 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Smith Fiberglass Products Company N/A <br />Component <br />Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />Piping Sump Testing, North <br />x x <br />Piping Sump Testing, South <br />x x <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />(Pages 2, 3, 5, 6, 7 N/A) <br />ONE BARREL OF TEST WATER LEFT ON SITE FOR CERTIFIED WASTE HAULER TO DISPOSE OF BY <br />GENERAL SERVICES. <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: Russe CC Chadwick Date: December 2, 2005 <br />Russell Chadwick <br />MAILED TO: Steven Shih, San Joaquin County Environmental Health Dept. <br />Copy To: Mr. Tom Valtierra, San Joaquin Co. Facilities Management Division <br />