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SWRCB,January 2002 • RECE4VEQ <br /> Secondary Containment Testing Report Form JAN 17 2012 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, writtEM1N) FAI MFALTH <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the FEW*�SEPMjQWncy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: C" U--AIJdODate of Testing: 'Z f I 2011 <br /> Facility Address: 50g tOODI�A` GpM CA. 9520 <br /> Facility Contact: Surinjeir Sin h Saini Phone: - tF� 3c4 <br /> Date Local Agency Was Notified of Testing: )1-,30-11 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: V-eU 1?TV2VLZt)1-d S l7 t e,Es ( C— <br /> Technician Conducting Test: G al a G Z <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Training <br /> Manufacturer Com oncrd s Date TraininR Ex ices <br /> 1tJc4D&-,). - STS l2- o ,. <br /> Cz-- GeV icc IW64 - 2g - n <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> bt�1JJLAVL 13'7 9 ❑ ❑ ❑ LIDC, '7 8 ❑ ❑ ❑ <br /> A,l"%.W— q l R ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> )tA2 pie-svL M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ►iy 4�'� id ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 15CV6DA¢. I 9 ❑ 1 ❑ ❑ 1 ❑ 1 ❑ ❑ 1 ❑ <br /> gEco IESCti R ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> S%)"IP z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ST P ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> X71cSkL -1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDS I 2_ '4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0DC, a d ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ix 56 ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,descnbe 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 docunsent are accurate and in full compliance with legal requirements <br /> Technician's Signature: - �� - � y Date: 12-11012.1c,11 <br />