Laserfiche WebLink
SWRCB, January 2002 RECENED- <br />Secondary Containment Testing Report Form , <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syftA4. Ue Me" <br />appropriate pages of this form to report results for all components tested The completed form, written t ~ <br />0 <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal lz$ <br />HILTH EPA <br />i vArn.nv mFnRMATInN <br />Facility Name: Teichert Mobile Equipment Date of Testing: 1/31/14 <br />Facility Address: 120 Frank West Circle, Stockton Ca <br />Facility Contact: Phone: <br />DateDate Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name: JP Petroleum Service <br />Pass Fail <br />Technician Conducting Test: Gabe Garcia <br />Component <br />Credentials: x CSLB Licensed Contractor <br />El SWRCB Licensed Tank Tester <br />License Type: A <br />Repairs <br />Made <br />License Number: 811471 ICC 4 5281582 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Ex ires <br />❑ <br />0 <br />0 <br />0 <br />Line 2 <br />x 0 <br />0 0 <br />MMUS 10 1Y.11 114,901 AN &IN-VI'MOWK <br />Component <br />Pass Fail <br />Not Repairs <br />Tested Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Line I <br />x 0 <br />0 0 <br />❑ <br />0 <br />0 <br />0 <br />Line 2 <br />x 0 <br />0 0 <br />❑ <br />0 <br />El <br />0 <br />0 0 <br />0 1 El <br />El- <br />El I <br />El <br />El <br />El <br />El El <br />0 <br />El <br />0 <br />-0 <br />-E] <br />El El <br />El 0 <br />El <br />El <br />El <br />0 <br />0 El <br />El El <br />El <br />0 <br />El <br />El <br />El El <br />0 0 <br />0- <br />El <br />0 <br />El <br />El 0 <br />0 0 <br />0-0 <br />El❑ <br />0 El <br />0 <br />0 <br />NEI <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />El 0 <br />El El <br />n <br />0 <br />El <br />El El <br />El El <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />-V7a�ter was filtered and retumed to holding tank. <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: <br />