COMPLIANCE INFO_2018 - Laserfiche WebLink

Home Browse Search

'REC'EIVED SW@C4,614402 Page of ��ondary Containment Testing Report Form ENVIRN rENTAL HEor useATT b contractors performing periodic testing of UST secondary containment systems. Use the � �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 owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: CDR-Tracy Boulevard Chevron I Date of Testing: 9/12/2018 Facility Address: 3775 North Tracy Boulevard,Tracy,Ca.95304 Facility Contact: Debbie I Phone: (209)836-9422 Date Local Agency Was Notified of Testing: 9/6/2018 Name of Local Agency Inspector(f present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Afford-a-test Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Types: A/Tank Tester License Numbers: CSLB Lic.#341375/SWRC13 Lic.#90-1120 Manufacturer Traini ' n� Manufacturer Component(s) Date Training Expires Caldwell Systems STP Piping Sump July 5, 2020 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Supreme 91 STP Piping Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F11 ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date:Date: September 12,2018