Laserfiche WebLink
• <br /> RECF.JVED <br /> NOV 15 2017 <br /> ENVIRONMENTAL HEALTH <br /> SWRCB,January 2002 DEPARTMENT Page-of <br /> 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 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:Valero Date of Testing: 11/8/2017 <br /> Facility address: 1210 E.Hammer In. Stockton ca. <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 11/6/2017 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Nucleus Pump Services <br /> Technician Conducting Test: Brian Roth <br /> Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A D40 License Number:949066 <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC#1-2 X El D D 11 11 ❑ <br /> UDC#5-6 X :1 ❑ ❑ 11 ❑ ❑ <br /> UDC#3-4 X L] ❑ ❑ 0 ❑ ❑ D <br /> UDC#7-8 * 9 ❑ 1 ❑ ❑ U ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ D D <br /> ❑ u ❑ D ❑ n ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ D <br /> ❑ D ❑ ❑ C D 11 ❑ <br /> D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ D ❑ ❑ C C <br /> ❑ G I ❑ I ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pumped water into trailor tank to be disposed in waste drums and labeled <br /> Found #7 & 8 UDC failing. Concrete broken in front of dispenser. Repair is being handle by <br /> another contracor <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated i this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: <br /> Date: 11/8/2017 <br /> FA 0003730 <br />