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06/05/2003 08:35 7753581 LA PERKS PAGE 11 <br /> Secondary Containment 'Vesting Report Form Page 1 of 2 <br /> Phis form is intended for use by contractors performing periodic testing of UST secondary coruainnJeW systems. Ilse the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if <br /> applicable), should he provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quik Stop#39 San Joaquin County) Date of Testing: 5/19/03 <br /> Facility Address: 2285 E. Freemont St, Stockton CA 95205 <br /> Facility Contact: Carolyn Edie Phone: 209-464-1038 <br /> County Contact: Fish Bri s Phone: 209-468-3468 <br /> Date Local Lkgencv Was Notified of Testing: <br /> Name of Local A enc Ins ector Present; <br /> 2. TESTING CONTRACTOR INFORMATION <br /> COM an Name: L.A.Perks Plumbing&Heating Inc. <br /> Technician Conductin Test: Keith.Perks <br /> Credentials: X CSLB Lioensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License jZge and#: A, C-36 HA.Z#678948 <br /> Training by Manufacturer <br /> Manufacturer Conn neats(s) <br /> CVI <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: 0 Number of Piping Runs Tested:0 <br /> Number of Submersible Plump Sums Tested:0 Number of UDC Boxes 'tested:0 <br /> Number of Fill Sum2s Tested:0 Number of Overfill Boxes Tested:2 <br /> Component Pass Fail Comments <br /> 87 fill X ❑ <br /> 91 fill X ❑ <br /> . .❑ ❑ <br /> ❑ ❑ <br /> c� ❑ <br /> ❑ 0 <br /> ❑ ❑ <br /> C7 ❑ <br /> ❑ ❑ <br /> Q ❑ <br /> ❑ Q <br /> ❑ CJ <br /> Technician's Signature: Date: 5/19/03 <br /> SWRCB <br />