COMPLIANCE INFO 2007 - 2010 - Laserfiche WebLink

Home Browse Search

SWRCB, January 2002 0 Page 1 . Secondary Containment Testing ReArt Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of 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: RYDER 1071A DateofTesting: 02/21/2007 Facility Address: 3633 DUCK CREEK DRIVE STOCKTON, CA, 95215 Facility Contact: MARK ARMSTRONG Phone: (209) 943-3213 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Fail Technician Conducting Test: HEATH MCEVER Component Pass Credentials: EICSLB Licensed Contractor Repair Made SWRCB Licensed Tank Tester E ❑ License Type: ILicense Number: D ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires El El El 7-1 ❑ ❑ ❑ ❑ / J ❑ ❑ / J 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 1 DIE FILL E ❑ ❑ ❑ D ❑ F-1 F-1 Spill Box 2 DIE FILL El El El 7-1 ❑ ❑ ❑ ❑ Spill Box 3 LUB FILL E ❑ ❑ E] ❑ �� 1:1 1:1Spill Box 4 WAS FILL � El El 71❑ 171 F7❑ F7 El El E 71 171 F7 [ LI El F1 7 171 F F71 - El ❑ El EJ 1:1 1:1 1:1 El Ll F1 ❑ E Ll L] L] El El F El 1:1 El El El El E E El El E] 1EIIE] E ElI E If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: 1 Date: 02/21/2007