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e <br />SWRCR, January 2002 <br />DEG 1 6 H,9? <br />ENVI R (j ; _ _ ,LTH Page 1 of 7 <br />Secondary Containment Testing ReportP rm - % "ES <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages <br />of this form to report results for all components tested. The completed form, written test procedures, 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: SAN JOAQUIN COUNTY, DOWNTOWN PARKING GARAGE Date of Testing: 12/05/02 and 12//06/02 <br />Facility Address: 121 S. San Joaquin Street, Stockton, CA 95202 <br />Facility Contact: Earl Gilford Phone: <br />Date Local Agency Was Notified of Testing: 11/25/02 <br />Name of Local Agency Inspector (if present during testing) N/A <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: James Payton <br />Credentials: IX I CSLB Licensed Contractor I I SWRCB Licensed Tank Tester <br />License Type: C -61/D40 HAZ/HIC License Number: 309105 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />t u u 1 , YI ICR DRU 19 <br />Component <br />Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />TANK ANNULAR <br />X <br />SECONDARY PIPE <br />X <br />PIPING SUMP <br />X <br />UDC #1 <br />X <br />UDC #2 <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT AT SITE IN BARRELS LABELED AS HAZARDOUS. WILL HAVE A CERTIFIED WASTE HAULER HAUL <br />THEM OFF. <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 Signature: Date:/219 <br />Original Mailed To: <br />San Joaquin County Environmental Health Div. <br />Attn: Ray Von Flue <br />304 E. Weber Ave., Yd Floor <br />Stockton, CA 95202 <br />