Laserfiche WebLink
SWRC13, January 2002 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: 7 -ELEVEN 432262, MKT 2368 (N-3940-1 <br />DateofTesting: 04/08/2011 <br />Facility Address: 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA <br />Phone: (2 0 9) 83 0 - 9 917 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): Inspector Onsite <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />mmi�i=ff <br />Technician Conducting Test: <br />JON ADAMS <br />Credentials: <br />®®RIM <br />CSLB Licensed Contractor <br />' <br />SWRCB Licensed Tank Tester <br />- Spill Box 5 MID FILL <br />License Type: A <br />Manufacturer <br />License Number: 7 4 316 0 <br />Manufacturer TraininE <br />Component(s) <br />Date Training Expires <br />OPW <br />Spill Buckets <br />11/04/2011 <br />Spill Box 6 PRE FILL <br />I <br />iii <br />mmi�i=ff <br />, �� <br />, Cment <br />®®RIM <br />' <br />•1/,.• <br />- Spill Box 5 MID FILL <br />Elm= <br />Spill Box 6 PRE FILL <br />�i 4 <br />000 <br />��■ <br />00 <br />aa000 <br />0000 <br />0000 <br />0000 <br />�0000 <br />0000 <br />� �0000 <br />0000 <br />0000 <br />0000 <br />� �0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Treated with FM186 and removed from site <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the�factcs stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: A yo,�, C, -N Date: 04/08/2011 <br />