Laserfiche WebLink
SWRCB,January 2002 Page 1 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(if <br /> 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#20632,MKT 2368 jDate of Testing: 10/10/2018 <br /> Facility Address:4627 DA VINCI DR @ MARCH LN,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR(PTO#N-748) Phone:209-952-3543 <br /> Date Local Agency Was Notified of Testing: 10/10/2018 <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:Jarrod Cooke <br /> Credentials: rY—'. CSLB Licensed Contractor F—. SWRCB Licensed Tank Tester <br /> License Type:a ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 4/26/2020 <br /> L-- <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#TLRUL X <br /> Tank Annular#TIPUL X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water trailer <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: �J"� Date: 10/10/2018 <br /> WO:2338786 <br />