Laserfiche WebLink
' M i <br /> 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 <br /> (ifapplicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility Name:CHEVRON#201383(N-2515-1-1) jDate of Testing:2/15/2013 <br /> Facility Address: 1960 W. 1 I TH STREET t7 CORRAL HOLLOW,TRACY,CA 95376 <br /> Facility Contact:MGR-HELEN Phone:836-3181 <br /> Date Local Agency Was Notified of Testing:1/30/2013 <br /> Name of Local Agency Inspector(if present during testing):thuy <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Steven Willems <br /> Credentials: r CSLB Licensed Contractor r—SWRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> phil tite spill bucket 10/16/2014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Com Hent Pass Fail Not epai Com Not Repairs <br /> Tested Made ponent Pass Fail Tested Made <br /> Spill Box Tl supreme fill X <br /> Spill Box T2 plus 611 X <br /> Spill Box T3 regular fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECILNIICIAN RESPONSIBLE FOR CONDUCTII\'G THIS TESTING <br /> To the best of my knowledge,the1fa�cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ` Date: 2/15/2013 <br /> WO:2309192 <br />