Laserfiche WebLink
SWRCB,January 2002 Page 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: Tulare Farms,LLLPDate of Testing: December 11,2017 <br /> Facility Address: 2771 East French Camp Road,French Camp,Ca.95336 <br /> Facility Contact: Mike Edgar I Phone: (209)275-8555 <br /> Date Local Agency Was Notified of Testing: 11/14/2017 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Traini��g <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems UDC's July 5, 2020 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made _ Tested Made <br /> Annular Tank#I-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2-Unleaded X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#I-Diesel X ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#2-Unleaded X 1 ❑ ❑ ❑ ❑ ❑ j ❑ j ❑ <br /> ❑ ❑ ❑ ❑ a ❑ 1 ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse. <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: Fwd Date: December 11,2017 <br />