Laserfiche WebLink
TS7393-05 0 0 Page_1 of_4_ <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 ofthis form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHELL OIL PRODUCTS—STOCKTON TERMINAL I Date of Testing: 27 OCT 2006 <br /> Facility Address: 3515 NAVY DRIVE, STOCKTON,CA. <br /> Facility Contact: GERALD LANG I Phone: 209-466.6941 <br /> Date Local Agency Was Notified of Testing: 48 HOURS PRIOR(MIN.) <br /> Name of Local Agency Inspector(if present during testing): NIA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: MICHAEL L. STRAWN II <br /> Credentials: E CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin Ex ires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component ff Not Repairs <br /> Tested Made Tested Made <br /> TANK ANNULAR ❑ ❑ E ❑ ❑ ❑ <br /> PIPING SECONDARY ❑ E ❑ ❑ ❑PIPING SUMP ❑ ❑ ❑ ❑TRANSITION SUMP E ❑ ❑ ❑ ❑❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 10 <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ = ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ = ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL HYDROSTATIC TEST WATER WAS RECONTAINED IN THE SITES RECLAIM TANK AS <br /> GENERAL WASTE. NO HYDROSTATIC TEST WATER WAS REMOVED FROM SITE. NO NON- <br /> DRUMS WERE GENERATED AT TIME OF TEST. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fads stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 27 OCT.2006 <br />