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SWRCB January 2002 <br />> D' <br />Page _1_ of _8_ <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 for all components tested. The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CRLLC #5447 Date of Testing: 2/8/2011 <br />Facility Address: 1469 E. HAMMER LANE, STOCKTON, CA 95209 <br />Facility Contact: ARMEN MKRTYTCHIAN <br />I Phone: (925) 884-0800 <br />Date Local Agency Was Notified of Testing : 1/19/2011 <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A (CSLB Lic.) License Number: 803705 (CSLB Lic.) -- 06-1672 (SWRCB Lic) <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />/CC CA UST SERVICE TECHNICIAN #5254736 -UT DEC 28, 2012 <br />SCWRCB TANK TESTER LICENSE #06-1672 JUN 30, 2012 <br />FRANKLIN FUELING /NCON SUMP TESTER #5012133701 FEB 8, 2013 <br />LTA I LVA Ell 61,419111:i <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: -" Date: 2/8/2011 <br />91 (1) TANK ANNULAR <br />ItIlikiff"A <br />�� <br />DO� <br />' ' <br />0 <br />/ <br />►IN <br />��'�� <br />89 (2) STP SUMP <br />►1 <br />��� <br />�am <br />87 (3) TANK�/ <br />�a= <br />PRODUCT <br />am== <br />./ <br />0000 <br />// <br />a <br />= <br />M <br />�am <br />DIESEL (4) iSECONDA-. ROD�■�=/ <br />000 <br />ooao <br />amow <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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: -" Date: 2/8/2011 <br />