Laserfiche WebLink
SWRCB,January 2002 • Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completedform, written test procedures, and <br /> printouts from tests(rfopplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #32190 (N-3810) I DateofTesting: 07/31/2006 <br /> Facility Address: 4943 S. KINGSLEY MKT 2237, STOCKTON, CA, 95206 <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: RAYMOND SIMMS <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 87 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 91 X❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ Ell ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 01 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts statedin <br /> this document are accurate and infill compliance with legal requirements <br /> Technician's Signature: * ZOo--- Date: 07/31/2006 <br /> J <br />