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t N r SWRCB, January 2002 Page 1 of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Stockton CHP I Date of Testing: 2-6-07 Facility Address: 3330 North Ad Art Road, Stockton, CA 95215 Facility Contact: Joe or Justin Phone: 209-943-8643 Date Local Agency Was Notified of Testing; 1-23-07 Name of Local Agency Inspector (if present during testing): Toua Yang Z CTTMMARV nF TFCT RF,gTTT,TS Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Tested Repairs Made Tank # 1 — 87 Annular Space X ❑ ❑ 0 ❑ 0 0 ❑ Secondary Pipe # 1 — 87 X ❑ ❑ ❑ ❑ 0 0 ❑ Piping Sump # 1 — 87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC #% X ❑ ❑ ❑ ❑ 0 ❑ ❑ Fill Sump # 1 - 87 X 0 0 ❑ 0 0 ❑ ❑ Spill Bucket # 1— 87 X 0 0 ❑ 0 ❑ 0 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests Left sump test water in 55 gallon drums. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: A4Date: 49 - (, _, v-? t