Laserfiche WebLink
SWRCB,January 2002 Page 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 <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: CHEVRON 209167 Date of Testing: 03/20/2009 <br /> Facility Address: 1234 E. YOSEMITE AVE @ SPRECKLES, MANTECA, CA, 95336 <br /> Facility Contact: MANAGER - KIM Phone: (2 0 9) 824-7433 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: 5297793-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHILTITE INSTALATION <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 SUP FILL ❑ ❑ E ❑ ❑ FEl <br /> —1Spill Box 2 UNL FILLEl <br /> ❑ ❑ ❑ ❑ El ❑ <br /> Spill Box 1 SUP FILL ❑ Fx1 ❑ E ❑ El ❑ <br /> E El El E <br /> El El F-1 El El F� F-1 0 <br /> El F1 El El El El El <br /> El ❑ ❑ ❑ El ❑ ❑ 0- <br /> 1:1 El El <br /> El El El El <br /> El- <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> F1 El El El El El EL <br /> F1 El ❑ El <br /> E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK WATER WITH ME <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: 03/20/2009 <br />