COMPLIANCE INFO_2006-2015 - Laserfiche WebLink

Home Browse Search

't SWRCB, January 2002 DEC Page l of SSeeondary Containment 'Testing Rep I TALHEALTH PERMMSERVICES 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 ownerloperator for submittal to the local regulatory agency. Facility Name: City Of Stockton -Corp Yard Date of Testing: 12-11-12 Facility •,,ress: 1465 E. Lincoln Stockton,. 95206 Facilitv Contact: Maria Phone: 209-937-5642 Dat- Local Agency Was NotifiedTesting: Name of Local Ngenzy Inspeetoy Ofpresent during testing)*. rja Company Name: Henderson &faintenaacr Company - H?WC Technician Conducting Test: Charles Ferrucci Fail Credentials: 0 ❑ SWRCB Licensed TankTester License Type: Technicain Pass License Number: 856771 Manufacturer Manufacturer Training Component(s) Date Training Expires CON TS STS 0 u u ❑ ❑ ❑ r t r Component Pass Fail Not Tested Repairs Made Component Pass Fait Not Tested Repairs Made DEE SEL PROD LI"v'E EN 'T 0 u u ❑ ❑ ❑ ❑ ❑ ISPENSER 5/6 © ❑ ❑ ® ❑ ❑ ❑ ❑ DISPENSER 7/8 ® ❑ ❑ © ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Transported as test fluid. CERTIFICATION OF C riC i CONDUCTING ' To bestof rd , yr r' requirements Technician's Signature: Date: 12-112,11,7— .�//