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11(01I1ab5 14: 1L yb'J4tbf114 5D"IMLcr aIIVIU%UIVIIL1I� <br /> SWRcB January,2002 Job#: #7429132 PaF of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of rUSI secondary eorrtadnmCnt sy"sternv, U.se the <br /> appropriate pages of this forret to report results for all components tested, The completed form, written fest l racedures, and <br /> printouts from tests(ifapplicahle),should be provided to the facility awner/operator for submittal to the local regulatoryagency. <br /> Facility Name: Stockton,CA Switch Dake of Testing: 10128/2005 <br /> Facility Address: 3807 Coronado Ave Stockton CA 95204 <br /> Facility Contact: Ron Williams one: 20M37-SSOO <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency inspector(if present during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Shirley Environmental Testing <br /> Technician Conducting Test; Robert Soto <br /> credential-%: KCSM3 Licensed ContraL�—�2jicensm <br /> SWRCB Licensed Tank Tester <br /> Liccnse Type: Number:. <br /> .` mufac'turer'Lraining <br /> Ivlanufaeturcr Com ncnt(s) Date;Traiuin Es fres <br /> Incon TS-STS Analog Gauges <br /> 3. SUMMARY OF TEST RESULTS <br /> Component PM q Fail Not Repairs component Pass FailRiot iEcp�rina <br /> Tested Made 'Tested MAde <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ H <br /> L �►1_._.w 'i� t I <br /> -; <br /> Ir Ezydrost-atic test+ng ii is pezfo.rmed_describe what was done with the wjter after completion of tests: <br /> .SS <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TUTS TESTING <br /> To the hest of my kmmvledge,the facts stated in this doeuntoft are accurate and ire full compliance with b al requirements <br /> Technician Namc(print): Robert S <br /> Technician's Signature: <br /> Date: 1012812Q05 <br />