Laserfiche WebLink
jj <br /> i SWRC13,January 2002 NOV 2 g PLIJ I�-af� <br /> Secondary Containment Testing Report Form <br /> This oran is intended or'use b contractors er o,�ni,a <br /> f f Y p { gperlodie testing of UST secondary contabrnrerrti��Yf�t'i"fil�,��re <br /> appropriate pages of this form to report results for all components tested The completed form, u'ri;terr.>ie!d, 'pcect s-,,and <br /> printouts from tests(rf applicable),should be provided to the facility owner/aper atorfor submittal to the local regulatory agency. <br /> 1, IaACILITY INFORMATION <br /> Facility Name: Sprint Stockton Date of Testing: l I/07/2411 <br /> Facility Address: 3507 Coronado Ave.Stockton 95204 <br /> Facility Contact: Doye Phone: 217-663-9440 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresetrt during testing): Garrett Backus <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jauregui&Culver inc <br /> Technician Conducting Test: Peter Jauregui III <br /> Credentials: X CSLB Licensed Contractor 3 SWRCB Licensed Tank Tester <br /> License Type: A,B,C21,Haz License Number:708231 <br /> Manufacturer Training <br /> Manufacturer Cont oiuent s Date Trainin Ex fres <br /> Incon 7602133701 4-6-2013 <br /> ICC 5315297 6-22-2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass �T,, Nj, Repairs <br /> Tested �1adeDiesel sump UST X ❑ ❑ ❑ Diesei sump AST X ❑ I <br /> Spill bucket X ❑ 0 ❑ Piping secondary UST X ❑ ❑ ❑ <br /> Diesel annular UST ❑ ❑ X ❑ Piping secondary AST X ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> _T ❑ ❑ ❑ ❑ 11 Li El <br /> ❑ ❑ ❑ ❑ J=7 — — <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Water was deemed non-hazardous and removed at the time of test to be used <br /> On Future tests, <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the!rest of my knowledge,the facts stated in this document are accurate and in full compliance n4th legal requirements <br /> Technician's Signature: Date: 11/22/2011 <br /> I <br />