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SWRCB,January 2002 RECE�V� <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containments sa <br /> appropriate pages of thisform to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to tQAurgency. <br /> ENVIPO,N E dTAl <br /> 1. FACILITY INFORMATION HEALI'H DEPARTMENT <br /> Facility Name: San Joaquin General Hospital 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(if 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 /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Line#1 Supply x ❑ ❑ ❑ ❑ ❑ 0 0 <br /> Line#2 Return x ❑ ❑ ❑ ❑ ❑ 0 0 <br /> Sump 1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <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 /> Technician's Signa Date: ®� _ <br />