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~ e06705/2003 08:35 77535 11 LA PERKS PAGE 02 <br />Page 1 0r2 <br />Secondary Containment Testing Report Fox <br />This form is intended for use by cvntractors performing periodic testing of UST secondary containment sysre»ts. Ilse the appropriate <br />pages ofthis form to report Pr wits for all components tested lite completedform, written test procedures; and printouts from tests (,f <br />applicable), should be provi&d to the facidity owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Quik Stop #144 (San Joaquin County) Date of Testing -5/29/03 <br />Facility Address: 7272 West Lane. Stockton, CA 95210 <br />Tacilit Contact; H finder S Ba1'it K Ilundal Phone: 209-952-8812 <br />C2Lm Contact: Michael Kith Phone: 209-468-3444 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present: <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: L.A.Perks Plumbing &Heating Inc, <br />Technician Conducting Test;Keith Perks <br />Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type and #: A, C-36, HAZ #678948 <br />Tratinsng by Mmufactnarer <br />Number of Tanks Tested: 0 <br />Number of Pi in Runs Tested:0 <br />Number of Submersible Pump <br />Sumps Tested:0 <br />Number of UDC Boxes Tested:0 <br />Number of Fill Sum s Tested:0 <br />Number of Overfill Bones Tested: 3 <br />Component Pas: <br />Fail <br />Comments <br />87 fill X <br />o <br />89 fall X <br />❑ <br />91 rill X <br />❑ <br />❑ <br />Q <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />cr <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />Te0nician's Signature:_ 1,,C 71~Z-4Date: 5/29n}3 <br />SWRCB <br />