Laserfiche WebLink
Page 1 of S <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 of this form to report results for all components tested. The completed form, written test procedures, <br /> and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local <br /> regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Time Oil Co. Jack of Food Mart Date of Testing: 2-27-03 <br /> Facility Address: 1434 W. Yosemite Manteca CA 95336 <br /> Facility Contact: Al Younan Phone: 209-939-1792 <br /> Date Local Agency Was Notified of Testing: 2-24-03 <br /> Name of Local Agency inspector Present: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Oil Ecruipment Service <br /> Technician Conducting Test: James P. Hesketh <br /> Credentials: )1 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type and#: 323417 A-Haz C-10 C-21 C-51 , C61 -D40 <br /> Training by Manufacturer <br /> Manufacturer Component(s) tannExpires <br /> Owens Corning Pipe Sum 6/19/02 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: I Number of Piping Runs Tested: <br /> Number of Submersible Pum Sumps Tested One Niunber of UDC Boxes Tested: <br /> Number of Fill Sumps Tested, <br /> Number of Overfill Boxes Tested: <br /> Component Pass Fail Comments <br /> Plus Pipe Sump ja ❑ <br /> ❑ ❑ <br /> 11 D <br /> D ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ 0 <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> Technician's Signature: Date: 2-27-03 <br /> James' esket <br /> S WRCB December 2001 <br />