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r � <br />07/25/2003 09:35 <br />7753584 <br />LA PERKS 0 <br />Secondary Containment Testing Report Form <br />PAGE 02 <br />Page 1 of 2 <br />711is fort,: is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of thisjorm to report results for all components rested. The completed form, written test procedures, and printouts from tests (ff <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACHXrY INFORMATION <br />Facility Name: Quik Stop ##76 San Jo zein Cour Date of Testin :7/18/03 <br />Facility Address: 1030 So Olive Ave. Stockton, CA 95215 <br />Facili Contact: S. & Usha Harit Phone: 209-948-6731 <br />Cozen Contact- Tisk Briggs Phone: 209-468-3468 <br />Date Local ,Aenc Was Notified of Tessin <br />Name of Local Agency Ins tar Present: <br />2. TESTING CONTRAC'T'OR INFORMATION <br />Com an Name: L.A.Perks Plumbing & Heating Inc. <br />Te6nician Comductin Test: Keith Perks <br />Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License T and #: A, C-36 HAZ #678948 <br />Training by Manufacturer <br />Mantufacturcr Ccbn s <br />CNI <br />3. SUMMARY OF' <br />Number of Tanks Tested: 0 <br />Number of Submersible fum.2 Sumps Tested:0 <br />Number of Fill SUMPSTested:0 <br />Component PASS Fail <br />87 fill X 0 Passed 1 st test 5/19/03 <br />91 fill X ❑ <br />❑ 0 <br />❑ d <br />4 ❑ <br />ESULTS <br />Number of Pim Runs Tested:0 <br />Number of UDC Boxes Tested:0 <br />Number of Overfill Boxes Testi <br />© a * 87 fill passed 5/19/03 <br />❑ This is a retest of the 91 fill that failed on 5/19/03 <br />❑ ❑ <br />❑ o <br />❑ ❑ <br />a c� <br />❑ o <br />Technician's Signature: r Date: 18/03 <br />SWRCB <br />