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• <br /> SWRCB,January 2002 Page of_L. <br /> C? <br /> Secondary Containment Testing Report Form <br /> �� ��� <br /> 'Phis jbrm is intendedf n-use by conti'4tctor,4 petlurmirr�periodic testing of UST secondw y containment systems, fseS,1102009 <br /> he <br /> appropriate pages of this°jivni to report revults.for all components tested: The completed i,rm, written lest proc � s, 10 2007 <br /> printouts fi•orn tests (ij'applivahle), .should be provided to thefacility uwnerloperator.for submittal to the loct( ,a-re ncy. <br /> AL <br /> 1. FACILITY INFORMATION PiEn -T/^ +'�E- <br /> Facility Name: 44 oto 1, e 5 t-4 av - Bate of"resting: 1 a (1 <br /> Facility Address: r7 q q, 6e,54— WJCU(q I e4 ZU (� --- <br /> Facility Contact: t`'L{.t e,v "^a.Aj +- G^leen^ Phone: � <br /> Date Local Agency Was Notified of Testing: SU —T Jdae I eAe CG-C.-% W Sit.Q Pi <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t e�,,,. l ►�tl✓tc_4? "� �a <br /> Technician Conducting Test.'e �, " &: TVA w vm-r <br /> Credentials: Cl CSLB Licensed Contractor L WRCB Licensed Tank Tester <br /> License Type: .-AM1C, -e� ,V- License Number: �.I , E Vii' �/,d► <br /> Manufacturer Training <br /> Manufacturer Com onent(s) bate Training Expires <br /> --------------------------------- <br /> 3. SUMMARY OF TEST RESULTS <br /> a Not Repairs Component Peas Fait Not Repairs <br /> Caittpoc►ent Pass Fail Tested Made Tested Matte <br /> YYti1 the a/ �cw�1C_ 1 ❑ ❑ I7 �, . i ❑ L� I.j <br /> 41 f.P �GtM. <br /> - Ll ❑ El [l ❑ ❑ ❑ <br /> IALA <br /> El <br /> C[c V4 t P ❑ _ _ ❑ ❑ ❑ [ <br /> sec"4t ettt t I:J f 1 - - ❑ la ❑ [1 <br /> ❑ ❑ l7 CJ ❑ ❑ C� <br /> t $ -� [� LJ --- ❑ ❑ <br /> LA + ' 'SIC C, ❑ ❑ [ i1 [7 <br /> IFhydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> r . t" ��w•. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of'my knowledge,the facts.stated in this document are accurate and in full compliance with legal requirements <br /> T'echnician's Signature: 1 <br /> 5 S C. <br />