Laserfiche WebLink
iWRCB; January 2002 is 0 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 far all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable)„ should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />Facility Name: RYDER 1071A <br />Date of Testing: 02/05/2008 <br />Facility Address: 3633 DUCK CREEK DRIVE STOCKTON, CA, 95215 <br />Facility Contact: JOHN <br />Phone: (20 9) 943-3213 <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 />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made <br />Credentials: <br />X❑ <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />Tank Annular 3 LUB <br />License Type: a <br />I <br />License Number: 743160 <br />❑ <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/17/2009 <br />❑ <br />x i <br />�I�J <br />❑ <br />❑ <br />Fill Riser 9 USE <br />❑ <br />� X � <br />—J <br />u <br />1:1I <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Made <br />Tank Annular 3 LUB <br />❑ <br />ff] <br />F -1I <br />❑ <br />Fill Riser 4 USE <br />❑ <br />❑t <br />1:1 <br />u; <br />❑ <br />Secondary Pipe 3 LUB C <br />❑ <br />x i <br />�I�J <br />❑ <br />❑ <br />Fill Riser 9 USE <br />❑ <br />� X � <br />—J <br />u <br />1:1I <br />Secondary Pipe 3 LUB D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 3 LUB AONE❑ <br />❑ <br />❑ <br />- <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 3 LUB ATWO <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 5 ANT BONE <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 5 ANT BTWD <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 3 LUB <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 4 USE <br />x <br />❑ <br />❑ <br />❑ <br />El❑ <br />❑ <br />Fill Riser 1 DIE <br />E <br />�❑1 <br />I <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />F7 - <br />Fill <br />Fill Riser 2 DIE <br />I <br />❑ <br />❑ <br />171 <br />1:1 <br />❑ <br />Fill Riser 3 LUB <br />D-�] <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water doQ <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: 02/05/2008 <br />