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SWRCB, January 2002 Page hof <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondmy containment systems. Use the <br />appropriate pages of this form io 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: Date of Testing. Z <br />Facitity Address: 1 S C l o h P-1. ► C Ci , i 5 3 to4o <br />Facility COntact: to V-Llti Ooe L i Phone: 2 cam{ d <br />Date Local Agency Was Notified of Testing : Z t{ D 5 <br />Name of Local Agency Inspector (ifpresent during testingj: <br />2, TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Component <br />pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />pyo <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />UDS 23 5 12-qr-) <br />R 5 eL <br />Grd� 2,t 25M <br />U (} ';'t i f i3 <br />U V)L 25 Z& r-1 <br />Gt ��! +� � t ►� <br />> <br />> <br />> <br />u z6 s I z, M <br />> <br />U04 1►tit <br />D <br />LA (X 175 <br />ld�1r1Lµ�7 <br />�I <br />9 <br />:jD <br />� <br />u `!c ti 15 E �'� <br />J <br />J <br />f CM fzis, .{-a•nrw 'i'�t�` Z <br />J <br />It 41 L'? 4 is <br />D <br />7 <br />F;�I R;s�� ;N�..Y.l *'3 <br />Upc.4L lot i tv <br />F,i� R;sa, Co,.t4,��•�•+sw-`t <br />lnht.+' 21 t-11 <br />la 225 12-" rn <br />:1 <br />�] <br />:1 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this current ore a curate and in full compliance with legal requirements <br />Technician's Signature: w� [�-- Date: O <br />