Laserfiche WebLink
SWRCB,January 2002 Page of 8 <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> T/dv Jun..., ha.:... :.r uxc l y eunerarn.ry perJurndng perindlc tcvting of UST.vecandary cnntalnment systems. Ilse 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: Jackpot Food Mart I Date of Testing: 3/21 /03 <br /> Facility Address: 1400 Highway 88 Lockeford CA 95327 <br /> Facility Contact: Randy Haywood I Phone: 209-727-5442 <br /> Date Local Agency Was Notified of Testing: 3/20/03 <br /> Name of Local Agency Inspector(ifpresentduring testing): Dennis Catari a <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Equipment Service <br /> Technician Conducting Test: Keith A. Tallia <br /> Credentials: X CSLB Licensed Contractor U SWRCB Licensed Tank Tester <br /> License Type:A.Haz C61 D40 C10 C57 License Number: 323417 <br /> WINE <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Modern Welding Tanks 6/10/04 <br /> rontaintnt-ni- Sollitic)ns Pipe Sumps 6/19104 <br /> Ameron Pipe 1 / 31 /04 <br /> Bravo Dispenser Pans 9/24/04 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Paas Fail Not Repairs - Component Pala Fail Not Repairs <br /> Tested Made Tested Made <br /> Pipe Sump U UU U U U U <br /> Sup r Pipe SumpU IJ U u U u <br /> Plus pipe Sump U U u u U u u <br /> Reg. Sec. Pipe ix Li u 1i U U U U <br /> Super Sec, Pipe 11¢ u u U u u U U <br /> Plus Sec, Pipe U U U U U U U U <br /> U u u u u U u u <br /> U U U u U u u u <br /> U u u u u u u u <br /> U u u u u U u u <br /> U U u u u u u u <br /> U I u I u u u u u u <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> �LTaRt mAr3i um pumped hark to tank on test trailer. <br /> er <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,lh a s ated in this docum tare accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 6/23/03 <br /> ith A. Tal is <br />