Laserfiche WebLink
SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors perfoming 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 /> printoutsfrom tests(ifapplicable),should be provided to thefacility owner/operatorforsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: ARCO # 09600, CC 18022603 1 Dateof Testing: 03/26/2008 <br /> Facility Address: 1250 N. WILSON WAY , STOCKTON, CA, 95205 <br /> Facility Contact: MANAGER Phone: (209) 465-5359 <br /> Date Local Agency Was Notified of Testing: 03/18/2 0 0 8 <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH, License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 01/08/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Spill Box 1 REG FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 MID FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 SUP FILL 0 ❑ ❑ 1:11:1 <br /> ❑ ❑ ❑ <br /> 11 El [I F-1 El Ej F-1 IEl <br /> Ell 0 Ej El E <br /> El E El El El <br /> El El El <br /> El El El D <br /> ElEl E D Ej El El Ej <br /> E El Ej ED <br /> Q 0 El 0 E EI <br /> El F-1 F <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ONSITE. <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 f dl compliance with legal requirements <br /> Technician's Signature: 4 t ly/ Date: 03/26/2008 <br />