Laserfiche WebLink
SWRCB, January 2002 is <br />Page 1. <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 (fapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: CHEVRON #201383 <br />DateofTesting: 02/03/2012 <br />Facility Address: 1960 W. 11TH STREET @ CORRAL HOLLOW, TRACY, CA, 95376 <br />Facility Contact: HELEN - PERMIT: (N-2515-1-3) <br />Phone: (209) 836-3181 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): <br />CONTRACTOR2. TESTING INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: TIMOTHY <br />COULTER <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: UT -A <br />Manufacturer <br />License Number: 5295244-734160 <br />Manufacturer Training <br />Component(s) Date Training Expires <br />PHILTITE <br />SPILL BUCKETS <br />11/12/2011 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Component <br />i URI <br />Spill Box 3 REG FILL <br />Spill Box 1 SUP �IFILL <br />�0�0�_�����DDI <br />_♦1_00©� <br />_��1������� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />NONE CREATED <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: 02/03/2012 <br />