Laserfiche WebLink
Jec 0511 10:40a JP Petroleum Service 9163 72 4873 p.2 <br /> • SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> Thi.r form is intended for use by contractors performing periodic testing of UST secondary containment.rystems. Use the <br /> apprnpriate pages of thisform to repurl results far all components tested The completedform, written test procedures, mid <br /> pruitouts fram tests('(f applicable).should be provided to the facility nwiier/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORM-A ION <br /> facility Name: Arch Arco AM PM Date of Testing: 10-24-11 <br /> Facility Address: 4855 S.Hwy 99,Stockton Ca <br /> Facility Contact: Sonny Phone: 408-806-9148 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test Gabe Garcia <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 TCC#5281582 <br /> Manufacturer Training . <br /> Manufacturer Component(s) Date Trainine Ex fres <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested! Made <br /> UDC 5-6 x ❑ ❑ ❑ ❑ -1 F ❑ <br /> UDC 17-18 x C ❑ ❑ 7 C ❑ <br /> ❑ L J -J ❑ C ❑ :1 <br /> ❑ r ❑ 7 7 C ❑ <br /> ❑ ❑ ❑ 7 ❑ C ❑ � <br /> C ❑ ❑ — ❑ ❑ ❑ ❑ <br /> C ❑ ❑ C ❑ ❑ ❑ ❑ <br /> C ❑ ❑ L ❑ J J J <br /> 0 ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To Nie best of my knowledge,flte facis stated ut this document are accurate and int furl!compliance with legal rovalrem mis <br /> Technician's Signature:/:%1iGi�'C Ci�� _� — Date: <br /> 0 <br />