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SWRCR, January 2002 <br />Page 1 of'7 <br />Secondary Containment Testing Reppit �© <br />This form is intended for use by contractors performing periodic testing of UST secondary con s. Ushe appropriate pages <br />of this form to report results for all components tested. The completed form, written test%alad printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. d� <br />1. FACILITY INFORMATION <br />Facility Name: San Joaquin Co. Parking Garage <br />I Date of Testing: 2-10-03 <br />Facility Address: 121 S. San Joaquin Street, Stockton, CA 95202 <br />Facility Contact: Earl Gilford <br />Phone: 209-468-3099 <br />Date Local Agency Was Notified of Testin : <br />Name of Local Agency Inspector (if present during testing) Dennis Caten a <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Eric Mol acrd <br />Credentials: [X 1 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 />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />TANK ANNULAR SPACE <br />X <br />X <br />PIPING SUMP <br />X <br />X <br />UDC #1 <br />X <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER WAS LEFT ON SITE IN DRUM FOR REMOVAL BY CERTIFIED WASTE HAULER <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document area curate and in full compliance with legal requirements. <br />P <br />ATechnician's Signature: Date: February 10, 2003 <br />Eric Mo a <br />NOTE: ORIGINAL MAILED TO: <br />• San Joaquin County Environmental Health Division <br />Coat/ to: <br />• San Joaquin County, Mr. Earl Gilford, Motor Pool <br />