COMPLIANCE INFO_2006-2018 - Laserfiche WebLink

Home Browse Search

C 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Sutter Tracy Hospital I Date of Testing: 9/20/11 Facility Address: 1420 N. Tracy Blvd, Tracy Ca 95376 Facility Contact: Pedro Gonzalez Phone: 209-832-6032 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (ifpresent during testing): Thuy Tran 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Pass Technician Conducting Test: John Puumala Not Tested Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A Manufacturer License Number: 811471 ICC # 5252406 Manufacturer Training Component(s) Date Training Expires Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Tested Repairs Made Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Space 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ J ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ =0 ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. 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: Date: