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.. i <br /> ACDEH,August 2003 Page of <br /> r <br /> Secondary Containment Testing Report <br /> This form is intended for use by inspection staff performing testing during installation of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed forms, written test procedures, and printouts from tests <br /> (if applicable),shall be used in evaluating the installation of new equipment and repairs to existing equipment. <br /> 1. FACILITY INFORMATION <br /> Facility Name .ot p, C7g2S♦ Date of Testing: --I <br /> Facility Address: `5-79 k4. Ctr,46' w_ <br /> Facility Contact: A h Phone: <br /> Date Local Agency Was Notified of Testing: --1 _ _ t <br /> Name of Local Agency Inspector(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana/Bill McCarthy <br /> Cred s: x CSLB Licensed Contractor x SWRCB Licensed Tank Tester <br /> License Type:A Gen.Eng. #846288 License Number: <br /> Contractor's Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> In-Con TS- STS 1-23-2012 <br /> ICC TECH#5289227-UT <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> �� y4 ❑ ❑ ❑InL <br /> [� ❑ ❑ ❑ <br /> '1 ' i ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> r. L- L ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El <br /> ❑ ❑ ❑ ❑ El ElJEO , <br /> ❑ El <br /> El ❑ ❑ ❑ ❑ <br /> o <br /> USC, ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Inspector's Signatupe: <br /> Date:_ <br />