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S*iCB,January 2002 • • Page A--of� Secondary Containment Testing Report Form This form is intended for use by contractors performing pertodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and printouts from tests(!f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: j4 , C- , 5 a n D 5 Sc4- 6esn4-e,- Date of Testing: 2- 2.y it Oh Facility Address: t{gop ou-Ek A-ry o-e-1- WR S+oc*--IC, �, , 5�Ofl Facility Contact: -] oma, Ti E l Phone: o cl $ 2 - l S 5 Q Date Local Agency Was Notified of Testing : 2, t 0.6 Name of Local Agency Inspector(lfpresent during testing): (vl Lj vl; NA tau, TL.E, WL. 5. 2. TESTING CONTRACTOR INFORMATION pLicense ame, (L r �o, E �2�5� inej Conducting Test: [3 aw r u K tkh 3 i , :' ❑CSLB Licensed Contactor SWRCB Licensed Tank Tester pe:-rZ4.1 k Tia y LicenseNumber: p -t 12 Ursiniufacturer Component(s) Date Trainin Ex ires 3. SUMMARY OF TEST RESULTS Component Pass Fall Not Repairs Not Re airs Tested Made Component Pass Fail Tested Made tahu(ov- 74-* ❑ ❑ ❑ 2e4u.vn 1 to 5y v ❑ ❑ ❑ r4nvtulavTu�tlt2 ❑ ❑ ❑ TruK S ran n, v�K ❑ ❑ ❑ tyvI� 3 ❑ ❑ ❑ Trtu,Sr&tn a; to s ❑ o ❑ ScconoQ, #2 ❑ ❑ ❑ vuMSEl:un t �,,, 5 ❑ ❑ ❑ crMdea,v r ❑ ❑ ❑ S .11 Ovav�ilE v -I- p p ❑ ec{mmd a r `w3 ❑ ❑ ❑ ❑ $c cotdcc r `f ❑ ❑ ❑ vz✓ itE x ❑ ❑. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ STp i in Sit w. ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5t P c �h $Uw ❑ ❑ ❑ Re tta v✓i Tn K* Cl ❑ ❑ ❑ . ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: s I �utd sa�avlted a.�d fe co~-08 6HZ i fi CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To tJte best of my knowledge,the facts stated in this document are accurate and ht full compliance with legal requirements Technician's Signature:_ Date: