Laserfiche WebLink
SWRCB,January 2002 Page 1 of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (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 jDate of Testing: 1/11/2013 <br /> Facility Address:4344 E WATERLOO RD @ 99,STOCKTON,CA 95215 <br /> Facility Contact:MANAGER Phone:931-2186 <br /> Date Local Agency Was Notified of Testing:12/12/2012 <br /> Name of Local Agency Inspector(if present during testing):jeff w <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Steven Willems <br /> Credentials: F,CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:tanknology License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phi]the spill bucket 10/16/2014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box Tl supreme fill X <br /> Spill Box T2 reg unlead fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests:put in buckets with lids and <br /> take with me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefa11cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �J` Date: 1/11/2013 <br /> WO:2308164 <br />