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SWRCB, January 2002 Palt ^ f Secondary Contninment Testing Report Form ENVIR90 NTAL H This form is intended for use by contractors performing periodic testing of UST secondary containment systems. s EALTH appropriate pages of this form to report results for all components tested. The completed form, written testprocDERAWMENT 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: L o V t Date of Testing: j- f Facility Address: S r j� G COUNTY c,, �>L c Facility Contact: I Phone: Date Local Agency Was Notified of Testing: 6 -- 1 - I County Contact: � Q, In a rA i3,.y, G Name of Local Agency Inspector (ifpresent during testing): . F,h_a 2. TESTING CONTRACTOR INFORIV ATIOIN Company Name: L.A. Perks Plumbing & Heatin Inc. Technician Conducting Test U3 I Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, C-36, HAZ License Number: 678948 Manufacturer Component(s) WAVQ (1 . 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail I Not I Tested Repairs Made 7 ti( ti ❑ ❑ ❑ ❑ ❑ ❑ ❑ tf1C 2.L 21 ❑ ❑ ❑ ❑ ❑ ❑ 11 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 knowledge, the facts stated In this document are accurate and in full compliance with legal requirements Technician's Signature: ^- W.--. Date: `�