Laserfiche WebLink
�] <br />0 <br />SWRCB, January 2002 ■ l E 1�I� <br />M 1 <br />Secondary Containment Testing Report Form ^1�''nt� <br />Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment sys#llsV dmott1 <br />appropriate pages of this form to report results for all components tested The completedform, written test procedures, and <br />printouts from tests (ifopplicable), should be provided to the facility owner/operator for submit iR�l , agency (s <br />I V Anrr ITV rNFhRMATTnN DFPAoral�-. ��ii�.TH <br />- <br />Facility Name: JaMar Service Date of Testing: October 014 <br />Facility Address: 4075 East Main Street, Stockton, Ca. 95201 <br />Facility Contact: Jason Phone: (209) 464-1431 <br />Date Local Agency Was Notified of Testing: 10/17/2014, by Afford -A -Test <br />Name of Local Agency Inspector (ifpresent during testing): <br />7 mu Oc VXT! ! nNTV A9"rrn17 TNF11RM ATI(IN <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC 45246802 -UT <br />Manufacturer Trainine <br />Manufacturer Component(s) Date Training Expires <br />3 SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />p <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />Ll <br />11 <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />Secondary Pipe #2 <br />x <br />0 <br />❑ <br />0 <br />0 <br />0 <br />❑ <br />Piping Sump #1 <br />x <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />0 <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />0 <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />0 <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. <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: stfamllt-e.1/tuaazsa' Date: October 29, 2014 <br />