Laserfiche WebLink
SWRCB,January 2002 0 0 Page 1. <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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO #5450, CC 18022647 Dateo"fTesting: 05/31/2006 <br /> Facility Address: 1617 W. FREMONT , STOCKTON, CA, 95205 <br /> Facility Contact: DEALER/MANAGER Phone: (209) 462-1617 <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: TANKNOLOGY, INC. <br /> Technician Conducting Test: DENNIS RUE <br /> Credentials: ❑CSL13 Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pan Fail Not Repairs Component Pass Fail Not Repair, <br /> Tested Made Tested Madc <br /> Spill Box 87 MASTR <br /> F-1 F-1 El F-1 <br /> Spill Box 87 SLAVE0 F-1 El El <br /> El ❑ El En <br /> Spill Box 91 ❑ <br /> I v Ell F-11 ❑ El <br /> ❑ I El I F-1 El ❑I El El El <br /> 0101 ❑ El Ell El F-1 ET <br /> ❑ IF] I ❑ 0 F-11 0 El El <br /> ❑ I El I ❑ El El I ❑ ED F-1 <br /> ❑ I F-1 I ❑ I El ❑I Ell El El <br /> F-1 I El I El I El ❑11:11 El F1 <br /> ❑ I El I F-1 ❑ El I EJ El El <br /> ❑ El ❑ F-1 I ❑ El r_1 El <br /> El I El I F-1 El I El I F-1 El 0 <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 document are accurate and in full compliance with legal requirements <br /> Technician's Signature: #t--"e zt A Date: 05/31/2006 <br />