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06/05/2003 08:35 77535811 <br />LA PERKS 10 <br />Secondary Containment Testing Report Form <br />PAGE 02 <br />Page 1 Of 2 <br />This form is intended for use by contractors performtng periodic testing of LIST secondary containment Sys7e»ts Ilse the appropriate <br />pages ofthis form to report results for all components tested The completed form, written test prorzdures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Quik Stoy #144 (San Joaquin County) <br />Facility Address: 7272 West Lane. Stockton, CA 95210 <br />Facilityontact, Harinder S & Baljit K Hundal <br />County Contact: Michael Kith <br />Date Local Agency Was Notified of TestinZ_ <br />Name of Local Agency Inspector Present. <br />x. TESTING CONT] <br />Company Name: L.A.Perks Plumbing & HeatipS Inc. <br />Technician Conducting Test. -Keith Perks <br />Credentials: X CSLB Licensed Contractor <br />License Ty2e and 4: 1 C-36, HAZ 4678948 <br />111111111111111 <br />Training by <br />Manufacturer Comp <br />OPw <br />Number of Tanks Tested: 0 <br />Number of Submersible Pump <br />Number of Fill Sumps Tested:0 <br />3. <br />Tested:0 <br />Date of TestintZ:5/29/03 <br />Phone: 209-952-8812 <br />Phone: 209-4683444 <br />CTOR INFORMATION <br />❑ SWRCB Licensed Tank Tester <br />OF TESD' RESULTS <br />Number of Piping Runs Tested:0 <br />Number of UDC Boxes Tested:0 <br />Number of Overfill Bones Tested: <br />om onentass <br />Fail Comm�entl <br />87 fill <br />X <br />❑ <br />89 fill <br />X <br />❑ <br />91 fill <br />X <br />❑ <br />❑ <br />13 <br />❑ <br />❑ <br />L7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />Q <br />❑ <br />❑ <br />r� <br />❑ <br />❑ <br />Technician's Signature:T Z( JJ4Date: 5/29/03 <br />SWRCB <br />