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1 NN <br /> I 'S IRCB, January 20020 <br /> OB 2 5 LGLj Page f of <br /> Secondary Containment Testing kkVPW,1FPFPAL1h <br /> This form is intended for use by contractors performing periodic testing of LIST secoWvie or &s"systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be providedoo the facility owner/operator far submittal to the local regulatory agency: - <br /> 1. FACILITY INFORMATION <br /> Facility Name: ?";(w. S Te+ C. P = -ev I Date of Testing: 2, l (, <br /> Facility Address: ' $uU y o,A.41 A-1 r r,;-A- a.�j x! <br /> Facility Contact:_7rtA t vv{`. , l[; ( � Phone: (2-01 � `� $Z -1 5 5 C? <br /> Date Local Agency Was Notified of Testing :' I c? 0 'j <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t t 1) (,-,wit 1J 1 i ci,� <br /> Technician Conducting Test: { ».,,f us + tra <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: /c-----7;7-5 -eY License Number: -1-o-I <br /> Manufacturer Training <br /> Manufacturer Com ovens Date Training 1 x ires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> tJtktd{ 7W ❑ ❑ ❑ <br /> �iiru fr.✓ *+»lL � ❑ ❑ ❑ y{�.t/�fr�r A •t- �i�-- 7 � C�1'� ❑ ❑ ❑ <br /> ❑ 0 El C1 ❑ [I <br /> �t tar+��{t ,� ,i� �L ❑ ❑ ❑ i'"r?wSi""��.�y7 i i ����* MJ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> El El El ❑ ❑ ❑ ❑ <br /> ❑ ❑ 11 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was Pone with the water after completion of tests: <br /> �. (r+�-1 �u9 4)// r'j mac! I��r� cP.a vP�+"CtSC J� f`JJ ' . >�i.:s � <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,fit e facts stated In this document arc accurate and in full compliance wilt legal requirements <br /> Date: <br /> Technician's Signature:4]�.i 1 ' <br /> y <br />