Laserfiche WebLink
SWRCB, January 2002 <br />Page 1 of 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 appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 Date of Testing: 3/23/2012 <br />Facility Address: 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA 95376 <br />Facility Contact: CHANDRA Phone: 830-9917 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY `1-12ESULTS <br />Component <br />i C Component <br />Box pul PREMIUM F <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in buckets with lids and <br />take with me <br />CERTIFICATION OF TECBNICIAN 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: ` Date: 3/23/2012 <br />