Laserfiche WebLink
r SWR6%January 2002 Page of <br /> Secondary Containment Testing Repor4AP41117,006 <br /> This form is intended for use by contractors performing periodic testing of UST secon M Use the <br /> appropriate pages of this form to report results for all components tested The complete g _ cedures, 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: Grewal's Gas&Liquor f I Date of Testing: 1/3/06 <br /> Facility Address: 4100 E.Fremont Street,Stockton Ca 95215 <br /> Facility Contact: Rick I Phone: 209-463-5294 <br /> Date Local Agency Was Notified of Testing: 12/16/05 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> <Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> 3. SUMMARY, TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail <br /> Tested Made Tested Made <br /> Annular l Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular 2 Premium/Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line lPremiurn x 1 ❑ 1 ❑ ❑ ❑ 1 ❑ ❑ 1 ❑ <br /> Line 2 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 3 Regular x 0 , ❑ 0 ❑ ❑ ❑ 0 <br /> Sump 1 Premium x ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> Sump 2 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 3 Regular x ❑ ❑ ❑` ❑ ❑ ❑ <br /> UDC 1&2 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3&4 x ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> UDC.5&6 x ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> UDC 7&8 x ❑ ❑ _0 ❑ 0 ❑ 0 <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 /> Technician's Signa _ —�^ Date: 1,A-3Z0 6 <br />