Laserfiche WebLink
* 111 - K�"+f <br />0 <br />SWRCR, January 2002 �/ <br />Page I of 7 <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 appropriate pages,, <br />of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: DSS Company <br />Date of Testing: 2-7-03 <br />C Facility Address: 655 W. Clay Street, Stockton, CA 95206 _ <br />Facility Contact: Dennis Hunter <br />Phone: 209-948-0302 <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: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: Eric Mol aard <br />Credentials: [X ] CSLB Licensed Contractor SWRCB Licensed Tank Tester _{ <br />License Type: C -61/D40 HAZIHIC License Number: 309105 <br />Manufacturer <br />Manufacturer Training <br />3. SUMMARY OF TEST RESULTS, <br />Date Trainine Exuires <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />---, <br />Not <br />Tested <br />-- <br />Repairs <br />Made <br />i <br />SECONDARY PIPE <br />X <br />X <br />1 <br />{ <br />If hydrostatic testing was performed, 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 documem are urate and in full compliance with legal requirement;. <br />GTechnician's Signature: Date: February 7, 2003 <br />olgaard <br />NOTE: ORIGINAL MAILED TO: <br />• San Joaquin County Environmental Health Division <br />Copy to: <br />• DSS Company <br />