Laserfiche WebLink
lu 1 30 09 09: 05a JP Petroleum Service 9 16137 �' ��,,,;v� P. 1 <br /> 2ul1 y Page of <br /> SVIRCB,January 2002 <br /> Secondary Containment Testing ti, P` <br /> This form is intended for use by contractors performing periodic testing of UST sec '- bntarnment 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: Tracy Truck Stop Date of Testing: 7/28/09 <br /> Facility Address: 3940 N.Tracy Blvd,Tracy Ca <br /> Facility Contact: Debbie/Greg Phone: 209-401-2379 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A I License Number: 811471 ICC#5252406 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Trainin Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Line 1 Regular x ❑ ❑ ❑ ❑ ❑ C ❑ <br /> Line 2 Premium x ❑ ❑ G 0 ❑ ❑ G <br /> Line 3 Diesel x ❑ ❑ ❑ ❑ D ❑ <br /> ❑ ❑ ❑ D ❑ 0 ❑ <br /> ID ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> O ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <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 /> ate. <br /> Technician's Signa D ���/y_e'1 <br />