COMPLIANCE INFO_2011-2015 - Laserfiche WebLink

Home Browse Search

t SWRCB,January 2002 Page of 13 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Tracy Truck&Auto I Date of Testing: 2/12/2015 Facility Address: 3940 North Tracy Blvd., Tracy CA 95304 Facility Contact: Debbie Jutla I Phone: 209-832-5006 Date Local Agency Was Notified of Testing: 02/09/2015 Name of Local Agency Inspector(ifpresent during testing): Michelle Henry it 2. TESTING CONTRACTOR INFORMATION Company Name: Central Petroleum Maintenance Technician Conducting Test: Michael Spring Jr. MAR 0 9 2815 Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester " License Type: C61/D40 License Number: 491948 �� -rU m� An--ry97NIT Manufacturer Training Manufacturer Component(s) Date Training Expires Incon TS-STS Sump Test System 06/12/2015 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made #12/13A UDC X ❑ ❑ ❑ ❑ 0 0 0 #13/14A UDC X ❑ ❑ 0 ❑ 0 0 0 #14/15A UDC X ❑ ❑ ❑ 0 0 ❑ 0 #15/16 UDC X ❑ ❑ 0 ❑ 0 0 0 #17/18 UDC X 0 ❑ 0 ❑ 0 ❑ ❑ ❑ 0 0 0 ❑ 0 ❑ ❑ ❑ 0 0 0 0 0 0 0 ❑ 0 ❑ 0 0 ❑ ❑ 0 ❑ 0 0 0 0 0 0 0 0 0 0 0 ❑ 0 0 0 ❑ 0 0 0 ❑ 0 0 0 ❑ El0 0 0 0 0= If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test water placed in drums and removed for use as test water. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: