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A I °", SWRCB, January 2002 Page I 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. 9 T A 11 r x9r u r*Tuni?n4 A TinN 1. Name: Stockton CHP Date of Testing: 2-6-07 Address: 3330 North Ad Art Road, Stockton, CA 95215 Contact: Joe or Justin Phone: 209-943-8643 Fit ocal Agency Was Notified of Testing: 1-23-07f License Type: License Number: 03-1640 Local Agency Inspector (f present during testing: Toua Yang Manufacturer Training Com onent(s)Date Training Ex fres Not Tested ♦ --�" iwnrd-%- ] %Ar A TinN -- -o rb n nn 7 L. IfINlllrls l.Vty 1ru%%-I"Ek 11,411 u.�n. av-• Company Name: Dialysis North Technician Conducting Test: Greg Hartman ENVII?0NI�1c-N ` HEA Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester v License Type: License Number: 03-1640 Manufacturer Manufacturer Training Com onent(s)Date Training Ex fres Not Tested Repairs Made mponent FTankNot —Annular Space )( ❑ ❑ 3 SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests Leff sumo test water in 55 aallon 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: A Azk� Date: Pass Fail Tested Repairs Made Component Pass Fail Not Tested Repairs Made mponent FTankNot —Annular Space )( ❑ ❑ ❑ ❑ ❑ ❑ ❑ e # 1 — 87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump # 1 — 87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC ##/ X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Sump # 1 - 87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Bucket # 1 — 87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ [1 [1 [1 El u ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El El 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests Leff sumo test water in 55 aallon 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: A Azk� Date: