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SWRCR, January 2002 0 <br />Page I of " <br />Secondary Containment Testing Report Form <br />Stockton Service Station Equipment Co., 111c. <br />808 N. Union Street, Stockton, CA, 95205-4152 (209) 464-8333 FAX (209) 464-8349 <br />California Contractor License 309105 A-0611040 HADHIC E-mRil pstrcd�a4bcli,net <br />X. FACILITY INFORMATION <br />Facili Name; 1 Date of Testing: 2L • 7 - Q <br />FAcility Address: <br />Facili Contact: phone: <br />Date Local ,Agency Was Notified of Testing: �/ d <br />Name of Local Agency IMector if present during testing) <br />2. TESTING CONTRACTOR INFORMATIV1N <br />Com an Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: , ' � - ~ <br />Credentials: IX I CSLB Licensed Contractor SWRC$ Licensed Tank Tester <br />License Type: C+6III240 HA Z/HIC License Number; 309105 <br />Manufacturenin <br />Manufacturer Com orient S Date Training Ex ires <br />Smith Fiberi,lass Products Company NIA <br />3. SUMMARY OF TEST RESULTS <br />Component Fabs Fail Not Repairs Component Pnsa Fail Not Repairs <br />f I Tested I Made I I I I Teatrd I Made <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests; - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this doe ent are accurate and in full compliance with legal requirements. <br />Tecluiician's Signature: Date: <br />