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Page Lof <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 <br /> appropriate pages of this form to report results far all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TEICBERT AND SONS I Date of Testing: March 3,2005 <br /> Facility Address: 120 Frank West Circle, Stockton,Ca. 95206 <br /> Facility Contact: Mr. George Tnkeniori I Phone: 916-386-3716 <br /> Date Local Agency Was Notified of Testing: March 2005 <br /> Name of Local Agency Inspector(if present during testing): Diana-Stockton Cupa <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: Michael L. Strawn 11 <br /> Credentials: 0 CSLB Licensed Contractor El SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 FILL BUCKET 0 0 0 0 0 <br /> 87 VAPOR BUCKET 0 0 0 0 0 0 0 0 <br /> = 0 0 Cl 0 0 0 0 <br /> 0 0 0 0 <br /> 0 0 r-1 0 <br /> 0 0 0 0 0 a- <br /> -rr--n- 0 0 0 0 0 0 <br /> 11 0 0 — 11 0 -0--EF— 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL SB989 TEST FLUID WAS RECONTAINED IN ONE 30 GALLON D.O.T . APPROVED STEEL <br /> DRUM AND WAS REMOVED BY TESTING CONTRACTOR FOR PROPER DISPOSAL. NO <br /> FLUID WAS LEFT ON SITE <br /> CERTIFICATION OF TECHNICL4,N RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature Date: eW-60->- <br />