COMPLIANCE INFO_2016 - 2017 - Laserfiche WebLink

Home Browse Search

SWRCB,January 2002 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facili ID: PGE095 Client Name: Pacific Gas and Electric Company Date of Testing: 11/22/2016 Facility Address: 4040 West Ln. City: Stockton State: CA Zip Code: 95204 Facility Contact: Alex Steele Phone: 209-337-8902 ❑ Initial I❑Repair Test Date Local Agency Was Notified of Testing: 11/08/2016 ❑ 6 Month ❑Other Name of Local Agency Inspector(if present during testing): None Q Triennial 2. TESTING CONTRACTOR INFORMATION Company Name: TAIT Environmental Services Technician Conducting Test: Jerry Sanouvong Credentials: [E CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester Q ICC UST Service Technician License Type: A B ASB C-10 HAZ License Number: 588098 Manufacturer Training Manufacturer Component(s) Date Training Expires 1 CC 8061056 4/5/2018 Incon level 4 1016583708 10/21/2017 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Unleaded Sump ❑X ❑ ❑ ❑ Unleaded 2 UDC ❑X ❑ ❑ ❑ Unleaded Secondary ❑x ❑ ❑ ❑ Diesel UDC ❑X ❑ ❑ ❑ Unleaded Annular ❑x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Sump ❑X ❑ ❑ ❑ ❑ ❑ ❑ I ❑ Diesel Secondary ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel Annular ❑x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Vent Sump ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Sump ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Secondary ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Vent ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Annular ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Unleaded 1 UDC ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: All test water was left on site For any equipment capable of generating a print out of test results,you must attach a copy of the test report to this certification. ❑X System printout attached. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: % 5osel Date: 11/22/2016