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SWRCB, January 2002 <br />0 Page of <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 est„ prQc�4W and <br />printouts from tests (rf applicable), should be provided to the facility owner/operator for subm I _ agency. <br />__. <br />1. FACILITY INFORMATION <br />Facility Name: San Joaquin Hospital Eng. Plant Date of Testi , P,q 9 Y '6 <br />Facility Address: 500 Hospital Road, Stockton Ca <br />Facility Contact: Phone: ""' ' <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (afpresent during testing): <br />Company Name: JP Petroleum Service <br />Component <br />Technician Conducting Test: Gabe Garcia <br />Fail <br />Credentials: x CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: AJ <br />License Number: 811471 <br />Manufacturer <br />.1 ��� _ ,�s..,. __ . t� <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Line 1 Feed <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Line 1 Feed <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />Line 2 Return <br />x <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Sump 1 <br />x <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />1 0 <br />Fill Sump 1 <br />x <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ I <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ I <br />0 <br />0 <br />0 <br />0 <br />0 <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 the best of my knowledge, Phe facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date:�� jy <br />