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(applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: TE I CHERT CONSTRUCTION Date of Testing: 01/23/2008 <br /> Facility Address: 120 FRANK WEST CIRCLE STOCKTON, CA, 95206 <br /> Facility Contact: GEORGE Phone: (916) 386-3716 <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: MATTHEW HASLEY <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: 5259431-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology ALL 05/29/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 1 DIE0 ❑ ❑ ❑ El El <br /> Tank Annular 2 UNL x ❑ ❑ ❑ ❑ ❑ 1:1 ❑ <br /> Tank Annular 3 WAS X ❑ ❑ ❑ El F-1 F ❑ <br /> Secondary Pipe 1 DZE .BULK � IJ ❑ 1:1 1:10 ❑ <br /> Secondary Pipe 1 DIE BU X El ❑ ❑ ❑ <br /> Secondary Pipe 1 DIE DISP � ❑ ❑ ❑ ❑ F-1 ❑ El <br /> Secondary Pipe 2 UNL DISP ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 DIEEXI ElEl ❑ ❑ ❑ ❑ El <br /> Piping Sump 1 DIE X ❑ ❑ ❑ 0 ❑ F-1 El <br /> Piping Sump 2 UNL x El ❑ El F-1 ❑ El El <br /> UDC 1/2 ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 E ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> SITE TO 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: Date: 01/23/2008 <br />