Laserfiche WebLink
SWRCB,January 2002 Page 1. <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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON #99840 Date of Testing: 02/20/2009 <br /> Facility Address: 4344 WATERLOO RD @ 99, STOCKTON, CA, 95215 <br /> Facility Contact: MANAGER Phone: (2 0 9) 93 1-218 6 <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: BRIAN MCPHEELY <br /> Credentials: EICSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type. License Number: 8010965-ut <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> ss <br /> Made <br /> Spill Box 1 SUP FILL El ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 REG FILL x ❑ ❑ ❑ ❑ ❑ <br /> 0 El El E <br /> ❑ I ❑ I El ❑ ❑ ❑ ❑ <br /> El El El ❑ M El E <br /> El El F� El ❑ El F <br /> El D ❑ El F1 E <br /> El El F� El El El <br /> El El F� El El <br /> El El F1 El ❑ ❑ M El <br /> El El El El El ❑ F-1 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was left in the waste water drum on site. <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: Z.-'t` !/ Date: 02/20/2009 <br />