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SWRCB,January 2002 Page of 3 <br /> Secondary Containment Testing Deport Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Narne: San Joaquin General Hospital I Date of Testing: , 7/2/09 <br /> Facility Address: 500 West Hospital Drive Stockton Ca <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor ❑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 /> Not RepairsNot Repairs <br /> Pass Fail Component Pass Fail <br /> Component Tested Made Tested Made <br /> Line #1 Supply x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 42 Return x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's,Signatr. <br />