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a SWRCB,Januaijj2002 Page of Secondary Containment Testing Report Farm This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should he provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facilit) Name: Sprint Stock-ton. CA SwitchI Date of Testing: 1212103 Facility-Address: 3807 Coronado Avenue Stockton,CA 95204 (San Joaquin Count)) Facilit)-Contact: Ron Williams Phone: 209-937-5800 Date Local Agency Was Notified of Testing : Name of Local Agency inspector (if present during testing): 42 J 2. TESTING CONTRACTOR INFORMATION Compaiiy-Name: L.A. Perks Plumbing&Heating Inc. t „ Technician Conducting Test: Keith Perks Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Te License Type: A, C-36, HAZ License Number:. 678948 Manufacturer Training Manufacturer Component(s) Date Training E. ires Ameron Piping Western Fiberglass Sum Modern Sum 3. SUVINLARY OF TEST RESULTS Component Pass Fail Not Repairs,' Component Pass Fail Not Repairs Tested Made Tested Made Diesel Fill ■ G ' ❑ ❑ ❑ ❑ ❑ ❑ Tank Sump ■ 11 El ❑ ❑ ❑ 11 2 Transition Sump ■ ❑ ❑ ❑ ❑ 11 ❑ Piping Run I ❑ ❑ ❑ ❑ ❑ Piping Run 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1f h)-drostatic testing was performed describe what was done with the water after completion of tests: CERTIFICATIO F TECHNICIAN PONSIBLE FOR CONDUCTING THIS TESTING To the be.o of my knowledge, t 'facts stated in this doe ent are accurate and in full compliance with legal requirements Technician's Signa Date: 12/2/03