Laserfiche WebLink
SWRCB,January 2002 i 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(if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 DateofTesting: 12/14/2009 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GI L Phone: (2 0 9) 4 6 3-12 5 9 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 7 4 316 0 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repair <br /> Tested Made p Tested <br /> Tank Annular 2 REG El ❑ ❑ El ❑ ❑ D El- <br /> Tank <br /> Tank Annular 1 PRE x ❑ ❑ ❑ <br /> I� E F <br /> El <br /> El 1:1 El El <br /> El- <br /> El E El El ❑ El <br /> El El El E E El <br /> El El ❑ ❑ 00 E' ❑ <br /> El El El ❑ 1:1 El 7 <br /> El ❑ El Ll 1:1 1:1 El <br /> El El E El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> drums left on site <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 full compliance with legal requirements <br /> Technician's Signature: Date: 12/14/2009 <br />