Laserfiche WebLink
Page 1 of 9 ec(?( <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />Facility Name: 24 Hrs. Gas & Mart I Date of Testing: 08/28/2015 <br />Facility Address: 1901 S. EI Dorado St., Stockton, CA 95206 <br />Facility Contact: Sayed I Phone: (209) 207-1252 <br />Date Local Agency Was Notified of Testing: 08/26/2015 <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ECO-CHEKCompliance, Inc. <br />Technician Conducting Test: A. Steven Abano <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A License Number: 958763 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Instruments, Inc. Level Change Indicator N/A <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 550 gallon tank on a trailer and hauled for reuse as test water <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: Awit Date: 08/28/2015 <br />HE-GLIVEL, <br />