COMPLIANCE INFO 2003 - 2007 - Laserfiche WebLink

Home Browse Search

SWRCB, January 2002 Page 1. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondmy containment systems. Use the appropriate pages of this form to report results for all components tested. The completedfornn, written testprocedures, and printouts from tests frf applicable). should be provided to the facility owner/operator for submittal to the local regtdatoty agency. 1. FACILITY INFORMATION Facility Name: USA #110 DateofTesting: 06/08/2006 Facility Address: 2132 MARIPOSA ROAD STOCKTON, CA, 95205 Facility Contact: DEALER Phone: (209) 946-9282 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: JOEY MESA ComponentSpill Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: I License Number: Manufacturer Manufacturer Trainin¢ Component(s) Date Training Expires Spill Box 3-91 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, thefaets stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 06/08/2006 ComponentSpill Bc>x 1-87 Spill Box 2-89 Spill Box 3-91 Spill Box 4 -DIESEL 000 ��0®I If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, thefaets stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 06/08/2006