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MAR 05 2003 1:51PM LASERJET 3200 . P.1 <br />SWRCR, January 2002 Page 1 of 7 <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 />2. TESTING CONTRACTOR INFORMATION <br />Coin an Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Russell Chadwick 1 SWRCB Licensed Tank Tester <br />Credentials: [X 1 CSLB Licensed Contractor <br />License Type: C -61/D40 HAZ/HIC License Number: :09105 <br />Manufacturer <br />Component <br />Secondary Pipe Test, Boiler supply <br />Secondary Pipe Test, Boiler Return <br />Secondary Pipe Test, Generator <br />Secondary Pipe Test, Generator <br />Return — <br />Piping Sump Test, 01 North <br />Piping Sump Test, iia south <br />if <br />was <br />Manufacturer Training <br />irnmv%nnP.nt(4) Date <br />3. SUMMARY OF TEST RESULTS Nat Repairs <br />Pass Fail Not Repairs Component Pass R3u1 Tested Made <br />Tested Made <br />X <br />X <br />X1 I <br />X <br />X <br />X <br />deceribe what was done with the water after completion of tests: <br />Q2�tt C.�r�eis ce"'``A -c <br />CERTIFICATION OF tECHNICIAN RESPONSIBLE FOR CONDU TING THIS TESTING <br />To the best of my knowledge:iRus;sell <br />aadwick 'cument are accurate and in full compliance with legal requirements, <br />Technician's Signature: UJAA <br />Date: February 25, 2003 <br />NOTE: ORIGINAL MAILED TO: r <br />• San Joaquin County Environmental Health Division, <br />C01DY to: <br />y <br />• San Joaquin County, Mr. Bob Cawelti, Dept. of General Services <br />