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08102/2010 12:28 209-465-4988 HMC f SST PAGE 02/03 <br /> SWRCB,Janumy 2002 Page/of_ - <br /> Secondary Containment Testing Report For <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 T#te completed farm,written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACHM INFORVIATION <br /> Facility Name: CQUNFR.'Y SIDE MINI MART Date of Testing: 7-2-14 <br /> Facility Address: .14971 HWY 88,LODI,CA 95244 <br /> Facility Contact: EDDIE .Phone: 249-968-8553 <br /> Date Local Agency Was Notified of Testing: 7-2-10 <br /> Name of Local Agency Inspector(rfpresent during resting): <br /> i <br /> 2. TESTING CONTRACTOR]INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: U CSLB Licensed.Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester,Tecbmicain License Number.. 44-1677 <br /> ANanufacterm Training <br /> Manufacturer COMPOMAD .Date Trainin .E xpires <br /> 3. SUMNMY OF TEST <br /> ! Component pass Fall Nat R 'ars Co t Y Fait : Not irs <br /> Tested Made Tested budi <br /> 98/91/DSL ANNULAR X G 0 ❑ 0 0 D ❑ <br /> DC3C C 0 0 G <br /> ❑ ❑ u D ❑ a ❑ ❑ <br /> ❑ 0 0 0 Q.. 11 0. 0 <br /> fS 0 ❑ <br /> D i ❑ o a : : © ❑ o <br /> ❑ 0 0 4 <br /> Ct D D 0 D D.: 0. <br /> 0 0 D ❑ 0 © D 0 <br /> 0 0 © 0 L01 ❑ 0 <br /> D 0 G 0 G ' 'D 1j. G <br /> ❑ 0 0 a n D 0. 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion oftests: <br /> CERTIFICATION OF TECHNICIAN RESPONSI$LE FOR CONDUCTING THIS TESTING <br /> ?'e the best o,j'my knowte4e,thejarts st this drumad are accarate curd in fartl compliance wMh legal requirements <br /> Technician's Signature• Date. <br />