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SWRCB,January 2002 C e� <br /> Secondary Containment Testing; Report Form MAR I S 2010 <br /> This form is intended for use by contractors performing periodic testing of UST secondary contain"fWW"VIEWIMEALTH <br /> appropriate pages of this form to report results for all components tested. The completed form, written <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to th" A)t5ncy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas 4 Less I Date of Testing: 1/28/10 <br /> Facility Address: 3434 Manthey Road, Stockton Ca 95206 <br /> Facility Contact: Gilbert Silva Phone: 209-858-0101 x 319 <br /> ��D_ateLocal Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service f1 g"Iq cLp <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5252406 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made _ Tested Made <br /> Annular ❑ x 0 0 ❑ 0 0 0 <br /> Regular Sump x ❑ ❑ ❑ 0 0 0 0 <br /> Premium Sump x ❑ ❑ ❑ 0 0 ❑ ❑ <br /> Regular Line ❑ x ❑ ❑ 0 0 0 0 <br /> Premium Line 0 x 0 ❑ 0 0 ❑ 0 <br /> UDC 1-2 x ❑ ❑ ❑ 0 0 0 0 <br /> UDC 3-4 ❑ x ❑ ❑ 0 0 ❑ ❑ <br /> UDC 5-6 ❑ x ❑ ❑ _ 0 ❑ ❑ 0 <br /> UDC 7-8 x ❑ ❑ ❑ _ 0 0 0 ❑ <br /> UDC 9-10 ❑ x ❑ ❑ 0 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To lite best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> "-1--uian's Signa t �' '"""� - — Date:/ ����4� -- <br /> 53C, 1j <br />