Laserfiche WebLink
12-05-'14 13:11 FROM- West+tar Envmt Inc. +559-277-0106 T-538 P0002/0006 F-206 <br /> SWRCB,January 2002 • page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of 1IST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1, FACILITY INFORMATION <br /> Facility Name: CHARTER WAY CHEVRON Date of Testing: 1114/14 <br /> Facility Address: 508 W.CHARTER WAY <br /> Facility Contact: RAVINDER Phone: (209)992-1735 <br /> Date Local Agency Was Notified of Testing: 10/30/14 <br /> Name of Local Agency Inspeotor(if present during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: WEST STAR ENVIRONMENTAL <br /> Technician Conducting Test: STEVE WIT I EMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> LicenseTypc: License Number: 605/°(2 <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 27 3 <br /> x <br /> � x <br /> rJ A <br /> t ! <br /> r5 SG <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tem PARTMENT <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: 1114/14 <br />