Laserfiche WebLink
SWRCB, January 2002 A"8G 1- <br /> Secondary C®ntaonent Testingt!31 t For n* <br /> •This form is intended for use by contractors performing periodic testing of UST secondary containment 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 provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION i <br /> Facility Name: �`�d . } e A;� ("q,. Date of Testing: / 'r <br /> Facility Address: -111500 ''1 y20r:. PJ <br /> Facility Contact: -01 6 -ate ',, -i-1#t` Phone: <br /> Date Local Agency Was Notified of Testing : 0 <br /> Name of Local Agency Inspector(ifpresent during testing): t�',, <br /> 2. TESTINO'CONTRACTOR INFORMATION' <br /> Company Name: LFL70R bd — 1 f.S <br /> Technician Conducting Test: Z,jA1 F PV 1 r14 r x o / -b L,� Aj <br /> Credentials: ❑CSLB Licensed Contractor QSWRCB Licensed Tank Tester <br /> License Type:, License.Number: J J <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUMIIURY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail 'Tested Made Component Pass Fail Tested Made <br /> 1,7 <br /> C1 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ , <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> jV 47F �-'�9�i r r•.] f_'4`,��.aaa�'CF4..c �,y`• f,I,lj,'' ��� , . ,�;�' � 14 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in the tlocutne ire accufate and in fidl compliance with le;al requirements <br /> Date: <br /> Technician's Signature: / <br />