Laserfiche WebLink
eco <br />Page 1 of 8 <br />ECO-OHEK COMPLtArvCE <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, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1_ FACHJTV INFORMATION <br />Facility Name: Shell Date of Testing: 06/29/2011 <br />Facility Address: 16500 S. Harlan Road, Lathrop, CA 95330 <br />Facility Contact: Nick/Chris I Phone: (209) 983-038 <br />Date Local Agency Was Notified of Testing: 06/20/2011 <br />Name of Local Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />l/61'5: <br />- <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 55 gallon drums and hauled for reuse as test water <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: -N 7�x*o V -OV Date: 06/29/2011 <br />-Tor-ml . - - <br />0 <br />00 <br />0000 <br />� <br />l( <br />000 <br />0000 <br />0000 <br />0000 <br />0000 <br />000 <br />0000 <br />000 <br />0000 <br />0000 <br />0000 <br />000 <br />000 <br />��00 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 55 gallon drums and hauled for reuse as test water <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: -N 7�x*o V -OV Date: 06/29/2011 <br />