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D <br />SWRCR, January 2002 <br />40 <br />Page 1 of 7 <br />Secondary Containment Testing Report Forn 1 2003 <br />This form is intended for use by contractors performing periodic testing of UST secondary containments � tJ e the'appropi1� $ages <br />of this form to report results for all components tested. The completed form, written test procedu es , grlr#t r4\f elts (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. ' ° ` " <br />1' 1 <br />Facility Name: DSS Company <br />Date of Testing: 2-7-03 <br />Facility Address: 655 W. Clay Street, Stockton, CA 95206 <br />Facility Contact: Dennis Hunter <br />Phone: 209-948-0302 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing) <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Eric Mol card <br />Credentials: [X ] CSLB Licensed Contractor [ ] 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 />Pass <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 />SECONDARY PIPE <br />X <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this doc ept are ate and in full compliance with legal requirements. <br />Technician's Signature: Date: February 7, 2003 <br />EriC'Molgaard <br />NOTE: ORIGINAL MAILED TO: <br />• San Joaquin County Environmental Health Division <br />Copy to: <br />• DSS Company <br />