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i <br /> S WRCR, January 2002 <br /> t <br /> Page 1 of <br /> Secondary Containment. Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pag( <br /> of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> L FACILITY INFORMATION <br /> Facili Name: nick N' Save/Soho] Market <br /> Facili Address: 1901 S. EI Dorado St., Stockton, CA 95206 Date of Testin : Aril I5, 2003 <br /> Facili Contact Sam Sohol <br /> Date Local A enc Was Notified of Testin : March 17, 2003 Phone: 209.948-3005 <br /> Name of Local A enc inspector (if resent duringtestis ) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: Stockton Service Station E ui ment Co., Inc. <br /> Technician ConductingTest: Rand Chadwick <br /> Credentials: X CSLB Licensed Contractor <br /> License Type: C-61/D40 HAVHIC ) 'RCB Licensed Tank Tester <br /> License Number: 309105 <br /> Manufacturer Trainin <br /> Manufacturer Component(s) nnxires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs <br /> Tested Made Component Pass Fail Not Repairs <br /> Tank Annular Testin Re ular/Su er X Tested Made <br /> Seconda Pi a Testin #1 Fill Riser Containment Sum y <br /> X X S i1VOverfill Containment x <br /> Seconda Pi eTestin #2 X <br /> Pi in Sum Testin #I X <br /> Piping Sump Testing #2 X <br /> Under Dis neer Containment #1-2 X <br /> Under Dis enser Containment #34 X <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> TEST WATER LEFT ON SITE FOR A CERTIFIED WASTE HAULER TO PICK UP & DISPOE OF <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements. <br /> Technician 's Signature: Date: April 15, 2003 <br /> andy Cha wic <br /> ORIGINAL FAXED TO: Michele Sterni-Le, San Joaquin County Environmental Health District <br /> Copy Mailed To: Mr. Sam Sohol, Quick N' Save/Soho] Market <br />