Laserfiche WebLink
SWRCB, January 2002 • • Page _2_ of _9_ <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 from tests (if applicable), should be provided to the,facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ARCO #2093 Date of Testing: 311912015 <br />Facility Address: 3425 TRACY BL VD, TRACY, CA 94376 <br />Facility Contact: SARAH SAMUELS Phone: (360) 371 -81 -IA - - -- <br />Date Local Agency Was Notified of Testing : 314115 <br />Repairs <br />Made <br />Name of Local Agency Inspector ({f present during testing): NONE PRESENT <br />AtJN Z U cU13 <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANK-TEK ENVIRONMENTAL CORP. <br />€ <br />Technician Conducting Test: <br />RICHARD THOMAS <br />Repairs <br />Made <br />Credentials: ® CSLB <br />Licensed Contractor ® SWRCB Licensed Tank Tester <br />Fail <br />License Type: <br />A (CSLB Lic.) <br />License Number: 803705 (CSLB Lic.) -- 06-1672 (SWRCB Lic) <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />ICC <br />CA UST SERVICE TECHNICIAN #5254736 <br />DEC 5, 2016 <br />SCWRCB <br />TANK TESTER LICENSE #06-1672 <br />JUN 30, 2015 <br />FRANKLIN FUELING <br />/NCON SUMP TESTER #5012133701 <br />FEB 01, 2017 <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87(3) FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />87(3) VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 FILL BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 VAPOR BUCKET <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />— --- - <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />--- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />— <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT 4 LABELED 55 GALLON DRUMS ON SITE FOR LATER PICK UP <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, die facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: �_��.�___5 Date: 3119/15 <br />