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SWRCB,January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST 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. 1. FACILITY INFORMATION Facility Name: Stockton Unified School Dist Date of Testing: 12/16/05 Facility Address: 1923 El Pinal Stockton,Ca 95205 Facility Contact: Butch Smith Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(tfpresent during testing): none 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Technician Conducting Test: John Puumala Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number: 811471 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular 1 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular 2 Regular x ❑ ❑ 0 ❑ ❑ ❑ ❑ Line 1 Diesel x ❑ 0 ❑ ❑ ❑ ❑ ❑ Line 2 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sump 1 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sump 2 Regular x ❑ 0 ❑ ❑ ❑ ❑ ❑ UDC i&2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3&4 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5&6 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this cument are accurate and in full compliance with legal requirements T'echnician's Sign N - Date: