Laserfiche WebLink
SWRCB,January 2002 Page I of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), 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,MKT 2368 jDate of Testing: 12/18/2012 <br /> Facility Address:4943 S.KINGSLEY(FRONTAGE RD) HWY 99 @a ARCH AIRPORT RD,STOCKTON,CA 95206 <br /> Facility Contact:MGR-LORENA Phone:939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):not present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steven Willems <br /> Credentials: 17 CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:tanknology I.,'scensc Number:743160 <br /> Niamrfacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology secondary containment 9/2/2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Piss Fa rl Tested Made Component Pass Fail Tested Made <br /> Tank Annular#4 x UDC rt 1/2 X <br /> Tank Annular#5 X UDC#3/4 x <br /> Tank Annular#6 X UDC#5/6 x <br /> Secondary Pipe Test(Tank 4-rul) x UDC#718 X <br /> Secondary Pipe Test(Tank 4-rul) X UDC#9110 X <br /> Secondary Pipe Test(Tank 5-mul) x UDC#11112 X <br /> Secondary Pipe Test(Tank 5-mul) X <br /> Secondary Pipe Test(Tank 6-put) N <br /> Secondary Pipe Test(Tank 6-put) X <br /> S rP Containment for Tank 4 rul- I N <br /> STP Containment for Tank 5 mul- I X <br /> STP Containment for Tank 6 pul-1 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests:put in waterdog and take with <br /> me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �Y- Date: 12/18/2012 <br /> WO:2306817 <br />