Laserfiche WebLink
SWR .B,January 2002 Page 1-of_ . <br /> Secondary Containment Testing Report Form <br /> This firm is intended fir use by contractors pej.-Ibrining periodic testing of USTsecondaij?containment s'vsteins. 0e the <br /> appropriate pages oj'ihis.form to report results/irr all components tested. The compleled.form, ivriuen test procedures, and <br /> printouts front tests(if applicable), should be provided to the facility o"Werl I operalorfin-submittal to the local regulatory agency. <br /> 1FACII lqrx;' "NfORMATION <br /> A. It 1LSAM X %-,F <br /> Facility Name H&M KWIK SERVE BW98 Date of Testing 8/30/2017 <br /> Facility Address: 2501 E.JACKSON <br /> Facility Contact: MIKE Phone: (2#4*49(1 V h <br /> am MWM, <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ff'presew during testing): STACY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: LC SERVICES 5 Nh4 E,N TA I <br /> Technician Conducting Test: PETER WESTBROOK EPAR'J-ME�j: <br /> Credentials: X CSLB Licensed Contractor 1.j SWRC13 Licensed Tank Tester <br /> License Type: ICC License Number:B46675 <br /> Manufacturer Training <br /> Manufacturer Component(s) , Date Trainin-t_xP_ires <br /> INCON S0_1_Mp j'ESj.'FR 7/20/2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 STP X I <br /> 91 STP X I I <br /> DIESEL STP x 1") <br /> fi <br /> UDC 1-2 x I-] j ij <br /> Fail <br /> UDC 3-4 x 1--j <br /> 87 SECONDARY X 7 j <br /> 91 SECONDARY x <br /> DIESEL SECONDARY X <br /> 87 ANNULAR x <br /> DSL/91 ANNULAR x F__1 J <br /> If hydrostatic testing was performed.describe what was done with the water after completion of tests: <br /> RETURNED TO HOLDING TANK. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of aty knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's re� <br /> Sionatu Date: 5 t9 <br /> 0 � ­_ <br />