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SWRCB, January 2002 0 0 Page — of Secondary Containment Testing Report Form This farm is intended for use by contractors performing periodic testing of UST secondary containment systems, Use the appropriate pages of this form to report res tilts for all components tested, The completedform, written test procedures, and printouts from tests fff applicable), .should he provided to thefacility owner/operatnr for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: RYDER FACILITY LC -1071 ' Date of Testing: 10/10/08 Facility Address: 3633 DUCK CREEK DRIVE, STOCKTON, CA 95202 Facility Contact: Amy White � Phone: 713 4264800 Date Local Agency Was Notified of Testing: I0/08108 Test Type: in± Name of Local Agency Inspector fif present during testing): 7 TFCTTNC: CONTRACTOR INFORMATION Company Name: Bonsall Petroleum Construction. Inc.. Technician Conducting Test: Sergio Altamirano Credentials: X CSLB Licensed Contractor a SWRC13 Licensed Tank Tester License Type: A, I iAZ License Number: 682742 Manufacturer Training Manufacturer A Component(s)) Date Training Expires Incon STS 9126109 'I CiTN MARV OF TEST RVI;TTI,T:S Component 'Pass Fail Not Tested Repairs ,Itade Component Pass Fail Not Tested Repairs Made _ T-4 Annular X 7 ❑ I L C ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ii C ❑ 1 Cl ❑ ❑ ❑ ❑ ❑ ❑ 7 ❑ ❑ E FJ ❑ _ ❑ ❑ C' ❑ ❑ ❑ i ❑ ❑ ❑ ❑ ❑ ❑ 7 ❑ ❑ ❑ ❑ L L7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I.1 ❑ ❑ I ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Barrel left on site. CERTIFICATION OF TECHNICIAN RESPONSIBLE IrOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Date:*/7 /7 Technician's Signature:, _ l'