Laserfiche WebLink
I SWRCB, January 2002 <br />Page of <br />Secondary Containment Testing Report Form — <br />This form is intended far use by contractors performing periodic testing of UST secondary containment systems, jjselhe <br />appropriate pages ofthis form to report resultsfi)r all components tested They completed f <br />acility ownerloperatorfor submittal to the local regulatory agency. <br />printouts from tests (# 'applicable), should be provided to the facility orm, written test Procedures, and <br />-1 1. FACILITY -IN F 0— R M. A, T. I Ow N <br />Facility Name: Valley <br />Pacific Petroleum <br />Facility —Address: 1524 Fresno Ave., Stockton, CADate of Testing: 0-17-12 <br />Facility Contact: Mike Eliason Phone: <br />Date Local Agency Was Notified of Testing 10-10-12 . . . ...... <br />Name of Local Agency Inspector (if present during testing).* - <br />Stacie —Rivera <br />------------- <br />­­�- ­­­'). -- TESTING CONTRACTOR INFORMAIJON <br />Company Name: Kern County Construction, Inc. <br />Technician Conducting Test: Josh Simmons <br />.Credentials: x �CSLB Licensed Contractor <br />License Type: , B, Haz <br />E- SWRCB Licensed Tank Tester <br />License Number:481053 <br />Manufacturer Trainin-- <br />Date <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what w Lj I I <br />:K It tank for <br />re describe Ia. as done with the water after cornpletiot, attests: <br />Water <br />retUr��--_ <br />d to test <br />0 _U <br />CERTIFICATION OF T HNI 'IAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best ofmy knowledge, the facts 7ated it this document are accurate and in full compliance with legal requirements <br />Technician's Signature:__ <br />Date: 10-17-12 <br />