BILLING_2004-2007 - Laserfiche WebLink

Home Browse Search

S WRCB, January 2002 Page 1. Secondary Containment Testing Rept Form This form is intendedfor use by contractors performingpeppriodic testing of USTsecondary containment systems. Use the pr ntouis froma ests es (fapplicable),report should help ovideall d torthe facility owner/operatoonenistested. The afotr submittal to the loctten al regulatoand ry agency. 1. FACTLTTV TNFnRMSTTnty Facility Name: 7 -ELEVEN #32190 (N-3810)v"Date of Testing: 01/17/2007 Facility Address: 4943 S. KINGSLEY MKT 2237, STOCKTON, CA, 95206 Facility Contact: MGR - LORENA Phone: (209) 939-0679 Date Local Agency Was Notified of Testing Name of Local Agency htspector (if present during testing): 2. TESTING CONTRACTOR TNFnRNTATTnnr Company Name: TANKNOLOGY, INC._ v_v•_-'-_v, Pass Fail Technician Conducting Test: HEATH MCEVER Component Pass Credentials: NotTested Tested CSLB Licensed Contractor SWRCB Licensed Tank Tester Spill Box 4 REG FILL � License Type: ❑ License Number: ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires Spill Hox 5 MID FILL � ❑ ❑ ❑ El 1:1 ❑ ❑ Spill Box 6 PRE FILL El ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Made Component Pass Fail NotTested Tested Repair Made Spill Box 4 REG FILL � ❑ ❑ ❑ ❑ 1:1 ❑ ❑ Spill Hox 5 MID FILL � ❑ ❑ ❑ El 1:1 ❑ ❑ Spill Box 6 PRE FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ E Q-00 El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ Ej ❑ ❑ El El Ej Q ❑ ❑ 1:11-1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F -1O ❑ if hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECIINICLAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 01/17/2007