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,e S WRCB, January 2002 Page I of SSecondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment a RV appropriate pages of this form to report results for all components tested The completed form, writ lr t oc r 1 printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to c re tory agency. 1 _ FACILITY INFORMATION Facility Name: City Of Stockton Corp Yard Date of Testing: 1-3-13 Facility Address: 1465 E. Lincoln Stockton, Ca 95206 Facility Contact: Maria Phone: 209-937-5642 Date Local Agency Was Notified of Testing: Name of Local Agency Inspeetot (ipresent during testing); Stacy 2. TESTING CONTRACTOR INFORMATION Company Name: ,Heademon Maiatonza= Comp=y- HMC Technician Conducting Test: Charles Ferrucci Credentials: ® D SWRCB Licensed Tank Tester License Type: Technicain License Number: 856771 Manufacturer Manufacturer Training Co nent(s) Date Training Expires INCON TS STS 12-29-13 ::J r n t► _ � i its if hydrostatic testing was perfbrmed, tiescaibe what was done with the waterafter completion of tests: Transported as test fluid. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING ims TESTING To the best of my knowledge, the ads st din this dog nt are accurate and in full compliance with legal requirements J Technician's Signature: Date: 1 3-43 MM=10- x Component JMMFEM • ©o©rte ©n©o normo vv o o©o© o�ao mom_ if hydrostatic testing was perfbrmed, tiescaibe what was done with the waterafter completion of tests: Transported as test fluid. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING ims TESTING To the best of my knowledge, the ads st din this dog nt are accurate and in full compliance with legal requirements J Technician's Signature: Date: 1 3-43