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C] SWRCB, January 2002 Page -[-- of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: f t^ /1� f C �� Date of Facility Address: - Z • 6�k e ,/M Facility Contact: � r Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during t sting): 2. TESTING CONTRACTOR INFORMATION Company Name: , 617,= yl 4,7 Technician Conducting Test: /.9d Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: License Number: LJOId Manufacturer Manufacturer Training Component(s) Date Training Expires 0000 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowled a cts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: '1 (h f 0000 mom= '11000 00M0 00000000 . �. � o00 0000 o000 0000 MMMMMMMM=M mom= o00 mom= no= 000 MEMM= 000M MM 0 0000 0 _0000 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowled a cts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: '1 (h f