Laserfiche WebLink
SWRCB,January 2002 • 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(fapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #32190 (N-3810) , MKT 2368 DateofTesting: 01/28/2010 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <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: 743160 License Number: a <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology - all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 5 MID A <br /> Piping Sump 6 PRE ❑ ❑ El 11 <br /> El El El <br /> 0 El El F] El El El El <br /> El I El El <br /> El I El E El El El El <br /> Q Q El E <br /> ELI EEE:1 El El El <br /> E El El 1:1L1 El L1 <br /> Ej El El El <br /> El 1:1El El El <br /> El Eli El EEl I <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <br /> CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, the/facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Y^r"� Date: 01/28/2010 <br />