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SWRCR, January 2002 9 0 <br />Page 1 of 7 <br />Secondary Containment Testing Report Form <br />Stockton Service Station Equipment Co., Inc. <br />808 N. Union Street, Stockton, CA 95205-4152 (209) 464-8333 FAX (209) 464-8349 <br />California Contractor License 309105 A-C61/D40 HAZ/HIC E-mail ssseco(apacbeltnet <br />Facility Name: City of Stockton, Corporation Yard Date of Testing: Aril 9, 2009 <br />Facility Address: 1465 S. Lincoln Street, Stockton, CA 95206 <br />Facility Contact: Teri Williams Phone: 209.937-7416 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing) Ray Von Flue <br />I TTiQTTN(_ rnNTR 4f T(1R TNF(1T2MATIO <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Mark Henderson, California UST Service Tech #XX4141014045 <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 />'i_ MIMMARV OF TEST RESULTS <br />Component <br />Pass Fail Not <br />Tested <br />Repairs Component Pass Fail Not Repairs <br />Made Tested Made <br />Secondary Pipe Testing, <br />Page 3 <br />X <br />X <br />Piping Sump Testing, <br />Page 4 <br />X <br />X <br />Under -Dispenser Contain. <br />Page 5 <br />X <br />X <br />Spill/Overfill Contain. <br />Page 7 <br />X <br />X <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />PAGES 2 and 6 N/A <br />Test Results Faxed & Mailed to: SAN JOAQUIN CO. ENVIRONMENTAL HEALTH DEPT., MR. RAY VON FLUE <br />CITY of STOCKTON, MISS TERI WILLIAMS <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: Nark Henderson Date: April 9, 2009 <br />