Laserfiche WebLink
i <br /> RECEIVED <br /> SWRCB , January 2002 JAN ' fad of <br /> Secondary Containment Testing Report Fo EWIRONMENTAL HMLTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary conlainmeNk ( 1 . <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests (rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> i <br /> Facility Name : Gas Depot I Date of Testing: January 23 , 2018 <br /> Facility Address : 1330 East Yosemite Ave., Manteca, Ca. 95336 <br /> Facility Contact: Kevin Phone : (209) 825 -0332 <br /> Date Local Agency Was Notified of Testing . 12/ 11 /2017 <br /> Name of Local Agency Inspector (f present during testing) : <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: Affor&a-test <br /> Technician Conducting Test: Benjamin F. Duncan Jr. /ICC #5246802- UT <br /> Credentials : X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type : A License Number : CSLB Lic . #341375 /SWRCB Lic . #90 - 1120 <br /> r-- – 11 . F 1. <br /> — <br /> Manufacturer Training <br /> Manufacturer Component(s) _ Date Training Expires <br /> Caldwell Systems Piping Sumps/UDC ' s _ _ July 5 , 2020 <br /> 3 . SUMMARY OF TEST RESULTS _ <br /> Component Pass Fail Not Repairs Component Pass Fail Not 12epaiis <br /> Tested Made 7 ested Made <br /> Annular Tank # 1 X ❑ ❑ ❑ Dispenser Sump #9& 10 X ❑ ❑ ❑ <br /> Annular Tank #2&3 X ❑ ❑ ❑ Dispenser Sump # 11 & 12 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ . ❑ ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 _ X ❑ ❑ ❑ _ 1-1 Fj ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ —�_ ❑ ❑ ❑ ❑ <br /> Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ 1-1 ❑ ❑ <br /> Dispenser Sump #3 &4 X ❑ ❑ ❑ _ ❑ Li ❑ J <br /> Dispenser Sump #5 &6 X ❑ ❑ i ❑ ❑ G L3 <br /> Dispenser Sump #7&8 X ❑ ❑ Ll ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> Test Fluid Supplied and recovered for reuse. T <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 fill compliance with legal requirernents <br /> Technician ' s Signature : . 0xeW _—� Date : January 2 3 , 2018 <br />