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�'I 9,�CHV/ EL <br />SWRCB, January 2002 ¢> i �, 2 M05 page <br />1 of <br />i,'")R <br />Secondary Containment Testing Rep.i��V P0:ti- HEALTH <br />This form is uuended for use by contractors performing periodic testing of UST secondmy - Use the <br />appropriate pages of this form to report resulls for all components tester.. The completedform, wntlen test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency_ <br />1 CA1`ii iT\/ 1F&TT?d-%"­­W■ T <br />Facility Name: v f 2 S T�(u L ----V �� Zci a v Date of Testing: b 7 D <br />Facility Address: l S S 3 C O 1 R- k. i2 o Cq . `t 5- <br />a 3 <br />Fcility Contact: r� i C-� r� cO L Phone: Zpct _ p -7 c fU <br />Date Local Agency Was Notified of Testing : `Z Q j <br />Name of Local Agency Inspector (if present during testing): <br />Company Name: <br />Technician Conducting Test,: <br />F <br />Credentials: U CSLB I icensont ant <br />WRCB Licensed Tank Tester <br />l <br />License Type: M M T �� '��s'i �` <br />Manufacturer <br />License Number. <br />Manufacturer Trainia <br />component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component pyo Fail Not Repairs Cempoaent <br />-►1 h u( a v Tran !< n <br />_�4� ✓'Tel b1 �c <br />�nula✓Tcu�k� 3 - R <br />b!A 0, TA-A\L* 4 5 ' <br />Lon Act ; �y L <br />�t C -4w 11 v� ,,AA 1 2.� lN- <br />_tw`dQvW 1;it" _44 <br />eeorjav <br />If hydrostatic <br />2t'QuN�7 <br />was performed, describe what was done with the water after completion of tests: <br />\QKdQe<UuevZ b,� �' ��Gt•^t]l;tc.,.cvT�,-rah <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge the facts stated in document are accurate and in fuA comp&nce with legal requirements <br />Technician's Signature: c Date: %i <br />Made <br />MIN <br />Q QIM����� <br />QQ©Q©'� <br />was performed, describe what was done with the water after completion of tests: <br />\QKdQe<UuevZ b,� �' ��Gt•^t]l;tc.,.cvT�,-rah <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge the facts stated in document are accurate and in fuA comp&nce with legal requirements <br />Technician's Signature: c Date: %i <br />Made <br />