COMPLIANCE INFO_2008-2018 - Laserfiche WebLink

Home Browse Search

11 SWRCB, January 2002 Page of 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: Hammer Lane Oil I Date of Testing: July 15, 2015 Facility Address: 3304 West Hammer Lane, Stockton, Ca. 95207 Not Tested Facility Contact: Mike Singh Phone: (209) 992-1415 Component Date Local Agency Was Notified of Testing: 6/10/2015, by Afford -A -Test; z Name of Local Agency Inspector (f present during testing): 1 Annular Tank # 1 &2-87-91 .til 9 9 2 0 ' 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing >3 § ' ` s. Technician Conducting Test: Benjamin F. Duncan Jr. Not Tested Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester Component License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Systems Piping Sum s/UDC's July, 2015 Repairs Made Annular Tank # 1 &2-87-91 X ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank # 1 &2-87-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe # 1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. 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: Wm Date: July 15, 2015