Laserfiche WebLink
SWRCB,January 2002 Page`of <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 farm to report results for all components tested The completed form,written test procedures,and <br /> printouts from tests Cf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: City of Stockton,Co ration Yard Date of Testi : April 20,2018 <br /> Facility Address: 1465 Lincoln Street,Stockton,Ca.95206 <br /> Facility Contact: Maria Leos I Phone: (209)937-8060 <br /> Date Loo-al Agency Was Notified of Testing: 3/13/2018 <br /> Name of Local Agency Inspector(cf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./1CC#5246802-UT <br /> Credentials: X CSLB Licensed Contmetor X SWRCB Licensed Tank Tester <br /> License Type: A I License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer TralRine <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell S stems Piping Sum s/UDC's July 5,2020 <br /> 3. SUNUMEARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pi #3 X ❑ ❑ O ❑ ❑ ❑ ❑ <br /> Seconds P!E#4 : X ❑ .❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ d ❑ ❑ 1 ❑ ❑ <br /> Pip! Sump#2 X ❑ ❑ ❑ ❑ ❑ C ❑ <br /> Dis edser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dis nlser S!Lm2#3&4 X ❑ ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ <br /> Dispenser Sump#5&6 X 1 ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion.of teats: <br /> Test Fluid Supplied and recovered for reuse. <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. Date: Apri120.2018 <br />