Laserfiche WebLink
SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />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 completedform, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />Facility Nance: Valley Pacific Petroleum I Date of Testing: 5-7-2012 <br />Facility Address: 1524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: <br />Date Local Agency Was Notified of Testing: <br />514/2012 <br />Name of Local Agency Inspector (f present during resting): Stacy Rivera <br />� �c�rYtor� rnrr ru d("TC1R iNFf1RiN'ATTnN <br />x. 4TTMiNARV OF TEST RF,SULTS <br />r. <br />Component <br />Pass Fail <br />Not ' Repairs� <br />'Tested Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs„ <br />Made I <br />Satellite #1 piping <br />x D <br />Ll C <br />❑ <br />❑ <br />D <br />C-3 <br />❑ ❑ <br />D 0 <br />❑ <br />D <br />D <br />D <br />❑ ❑ <br />D ❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ c <br />❑ <br />L, <br />❑ <br />D <br />G L.J <br />❑ L_ <br />...._._ ... <br />U <br />❑ <br />t.� <br />_ <br />n <br />❑ <br />t.._i <br />CJ j..D <br />. <br />If hydrostatic testing was performed, describe' what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stat d in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:) Date:_5/712012_......... <br />