Laserfiche WebLink
SWRCB,January 2002 Page of <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/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: San Joaquin Regional Transit District Date of Testing: June 27&28,2011 <br /> Facility Address: 1533 East Lindsay Street,Stockton,Ca.95205 <br /> Facility Contact: Don Nichols I Phone: (209)943-1111 <br /> Date Local Agency Was Notified of Testing: 6/13/11 by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/ICC 45246802-UT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#7 X ❑ ❑ ❑ Piping Sump#3 X ❑ ❑ ❑ <br /> Annular Tank#8 X ❑ ❑ ❑ Piping Sump#4 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Piping Sump#5 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Piping Sump/Fill Sump#6 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Piping Sump#7 X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Piping Sump#8 X ❑ ❑ ❑ <br /> Secondary Pipe#5 X ❑ ❑ ❑ Dispenser Sump #1 X ❑ ❑ ❑ <br /> Secondary Pipe#6 X ❑ ❑ ❑ Dispenser Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe#7 X ❑ ❑ ❑ Dispenser Sump#3 X ❑ ❑ ❑ <br /> Secondary Pipe#8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X I ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <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 by R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated Inn'this <br /> �document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ' J`. lltytcasa Date: June 27&28.2011 <br />