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7-7 <br /> SWRCR,January 2002 Page I of 7 <br /> 105 <br /> Secondary Containment Testing FmVp <br /> qt Form <br /> i HEALTH <br /> P&iVICES <br /> Stockton Service Station Equipment CO." <br /> 808 N. Union Street, Stockton, CA 95205-4152 (209)464-8333 FAX (209) 464-8349 <br /> California Contractor License 309105 A-C6l/D40 HAZ/HIC E-mail sssecoi—gipacbell.net <br /> 1. FACILITY INFORMATION <br /> Facility Name: City of Stockton I Date of Testing: November 21,2005 <br /> Facility Address: Corp Yard, 1465 S.Lincoln Street,Stockton,CA 95206 <br /> Facility Contact: Phil Burnside Phone: 209.937.7417 <br /> Date Local Agency Was Notified of Testing: 11/07/2005 <br /> Name of Local Agency Inspector(if present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Stockton Service Station Equipment Co.,Inc. <br /> Technician Conducting Test: RusFsell'Chadwick <br /> Credentials: [X] CSLB Licensed Contractor SWRCB Licensed Tank Tester_ <br /> License Type: C-61/D40 HAZ/HIC License Number: 309105 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Smith Fiberglass Products Company N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> I Tested Made Tested Made <br /> Secondary Pipe Testing,Page 3 x <br /> Piping Sump Testing,Page 4 x <br /> UDC Testing, Page 5 x <br /> Spill/Overfill Containment Boxes,Pg.7 x <br /> Spill/Overfill Containment Boxes,Pg.7 x DIESEL FAILED <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> (Pages: 2, 6,N/A) <br /> THREE (3)DRUMS OF WATER LEFT ON-SITE <br /> CERTIFICATION OF TECHNICIAN RESPONS!BLE 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: Pusse CC Chadwick Date: November 21,2005 <br /> Russell Chadwick <br /> MAILED TO: Michele Le,San Joaquin County Environmental Health District <br /> Copy To: City of Stockton <br />