Laserfiche WebLink
SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report For <br /> This forrn is intended for use by contractors performing periodic testing of UST secondan,containment systems. Use the <br /> appropriate pages of thisform to report results for all compponents tested: The completed form, written test procedures, and <br /> printouts from tests(rf applicable),should be provided to the.facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CHEVRON 208118 Date of Testing: 04/25/2006 <br /> Facility Address: 3355 E. HAMMER LANE STOCKTON, CA, 95212 <br /> Facility Contact: MANAGER Phone: (2 0 9) 477-3699 <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: RAYMOND SIMMS <br /> Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> / <br /> EE] <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2x —1❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ D <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ II ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ I ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ El . ❑ ❑ <br /> O ❑ ❑ ❑ ❑ L ❑ ❑ ❑ <br /> If hydrostatic testing was perfonned,describe what was done with the water after completion of tests: <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: 04/25/2006 <br />