Laserfiche WebLink
SWRCB , January 2002 Page of <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 fronr tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Quick Shop Date of Testing : April 25 , 2018 <br /> Facility Address : 2072 West Yosemite Ave . , Manteca, Ca. 95337 <br /> Facility Contact : Pete Chahoud Phone : (209) 3454689 <br /> Date Local Agency Was Notified of Testing : 3/ 13 /2018 <br /> Name of Local Agency Inspector (Not present for all testing) : Elena Manzo , REHS <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : Afford-a-test <br /> Technician Conducting Test: Benjamin F . Duncan Jr. /ICC #5246802-UT <br /> Credentials : X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type : A License Number: CSLB Lie . #341375/SWRCB Lie . #90- 1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC ' s July 5 , 2020 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank # 1 X ❑ ❑ ❑ Piping Sump #4 X ❑ ❑ ❑ <br /> Annular Tank #2 &3 X ❑ ❑ ❑ Piping Sump # 5 X ❑ ❑ ❑ <br /> Annular Tank #4 , 5 &6 X ❑ ❑ ❑ Piping Sump #6 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ ❑ ❑ Dispenser Sump # 1 &2 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump #3 &4 X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump #5 &6 X ❑ ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ Dispenser Sump #7 & 8 X ❑ ❑ ❑ <br /> Secondary Pipe # 5 X ❑ ❑ ❑ Dispenser Sump #9 & 10 X ❑ ❑ ❑ <br /> Secondary Pipe # 6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> Test Fluid Supplied and Recovered for reuse . <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician ' s Signature : Date : April 25 , 2018 <br />