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SWRCB, January 2002 • • Secondary Containment Testing Report Form Page of This form is intended for use by contractors performing periodic testing of LIST 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 4. FACILITY INFORMATION Facility Name: RYDER FACILITY LC -1071 Date of Testing: 212$105 Facility Address: 3633 DUCK CREEK DRIVE, STOCKTON, CA 95202 Facility Contact: AMY)WHITE Phone: 713 426 4800 Date Local Agency Was Notified of Testing : 2122/05 Test Type: 6 months Name of Local Agency Inspector (if present during A TF.cT1NC; CONTRACTOR INFORMATION 6. SUMMARY OF TEST RESUL YS Component p Pass Fail Not Repairs Tested Made Component Pass Faii Not Tested Repairs Made T-1 Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ T-2 Spill Bucket T-3 Spill Bucket X X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ T-4 Spill Bucket X ❑ ❑ ❑ ❑ ❑ _ ❑ T -I Annular T-2 Annular X X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ T-3 Annular X ❑ ❑ ❑ ❑ ❑ T-4 Annular X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledg a facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: Q- U