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F .& 4 <br />SWRCR, January 2002 0 <br />n <br />Page 1 of 7 <br />Secondary Containment Testing Report Form <br />Stockton Service Station Equipment Co., Inc. JUN 2 9 200 <br />808 N. Union Street, Stockton, CA 95205-4152 (209) 464-8333 FAX (20 4 HEA i <br />California Contractor License 309105A-C61/1340HAZ/HIC E-mail ssseconapacbell.n ERS 1l1 SERVICES <br />1 _ FACILITV INFORMATION <br />Facility Name: City of Stockton I Date of Testing: 6/25/04 <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: <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: Eric Mol aard <br />Credentials: [X ] CSLB Licensed Contractor [ ] SWRCB Licensed Tank Tester <br />License Type: C-61/1)40 HAZ/HIC License Number: 309105 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Smith Fiberglass Products Company N/A <br />kARIN05 10 F-111 ►'` 1 <br />Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />Spill/Overfill Containment Boxes X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Pages 2, 3, 4, 5, 6 N/A <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: Erick No(gaard Date: June 25, 2004 <br />Eric Molgaard <br />NOTE: ORIGINAL MAILED TO: San Joaquin County Environmental Health Division <br />