Laserfiche WebLink
WRC33,January 2002 rhe_I ofd <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary contaitment systems. Use the <br /> appropriate pages of thisform to report results for all co►npownts tested The completedform, written test procedures, and <br /> prirntouts from tests(rf applicable,), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facjli Name: Gas 4 Less I Date of Testing: 1128110 <br /> Facility Address: 3434 Mu they Road,Stocldon Ca 95206 <br /> Facility Contact. Gilbert SRva Phone: 209-858-0101 x 319 <br /> Date Local Agency Was Notified of Testing <br /> Na=of Local Agency Inspector(Ypresettt during Jesting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name- JP Petrolewn Service e e–Il 9112 'FC/47- q46'5- <br /> Technician <br /> 46 —Technician O mducting Test: John Paumala <br /> CredentiaL: x CSLJ3 Licensed Contractor 0 SWRCD Licensed Tank Tester <br /> License Type: ,A. License Number: 811471 ICC ff 5252406 <br /> Manufacturer Trsinina <br /> Manufacturer component(s) Date Training E ices <br /> 3. SU INIARY OF'TEST RESULTS <br /> Component Pass Fail Not Repay Compontat pass Fail Not Repairs <br /> Testred Made Tested Made <br /> Annular ❑ x ❑ ❑ ❑ Cl ❑ ❑ <br /> Regular S1unp x ❑ ❑ ❑ ❑ ❑ ❑ Q <br /> Premium Sump x ❑ ❑ ❑ 7 ❑ ❑ ❑ <br /> Regular Line ❑ x ❑ ❑ 7 ❑ ❑ ❑ <br /> Premium Line ❑ x ❑ ❑ ❑ ❑ 0 0 <br /> UDC 1-2 x D ❑ ❑ ' ❑ ❑ 0 <br /> )UDC 3-4 ❑ x D ❑ D 7 ❑ 1 ❑ <br /> UDC 5-6 0 x ❑ ❑ ❑ L ❑ ❑ <br /> UDC 7-8 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9-10 ❑ x ❑ p 0 ❑ ❑ Cl <br /> ❑ ❑ ❑ 0 1 ❑ ❑ C ❑ <br /> ❑ ❑ ❑ 0 C7 ❑ ❑ ❑ <br /> If hy&ostatic testing was performed,describe wbat was done with the water after completion ortests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTJNG <br /> To the best of my knowledge,the facts started fit this document are aecurate and fn JW cmnpUance with legal requirements <br /> Technician's Signa �^ <br /> 6'd 9L LO-btrL-60Z .LSE1V(j i0z1dd dZ�:ZL 06 Z6 cl;R-j <br /> 200 'd 80108086021 'ON X SS31 U Q00� Yid H :90 HV010Z/00AM <br />