Laserfiche WebLink
SWRCB, January 2002 1 . <br />Secondary Containment Testing Re�rt Form Page <br />This form is intended for use by contractors performing per -iodic 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, and <br />printouts fi-om 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: 7 -ELEVEN # 19976 MKT 2237 <br />DateofTesting: 04/26/2007 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE , MANTECA , CA, 95336 <br />Facility Contact: BEN <br />Phone: (2 0 9) 239-3252 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />BRYAN KEYS <br />Credentials: <br />❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />Spill Box 91 1 <br />License Type: <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />000 <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 04/26/2007 <br />Spill Box 91 1 <br />000 <br />��00 <br />000 <br />��00 <br />0000 <br />��OD <br />0000 <br />��00' <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 04/26/2007 <br />