Laserfiche WebLink
May 05 04 03: 22p (209749-0112 p. 9 <br /> S WRCD,January 2002 S i page_of_ _ <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of USTsecondary containmentsystems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written lest procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: a 0 r jDateofTesting: Z,/-- I.6' 1 <br /> Facility Address: fN u r I9 <br /> Facility Contact Phone' <br /> Date Local Agency Was Notified ofTesting: e <br /> Name of Local Agency Inspector(rfpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION` ' <br /> COMP=Narne: .7rr <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB License Contractor RCB Licensed Tank Tester <br /> License Type:. License dumber. <br /> Manufacturer Traininr <br /> Manufacturer _ Component(s) Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not ReptriMNot Repair <br /> Component PAWFad Tasted Made Component F' Fad Tented Mode J <br /> ❑ ❑ ❑ 1,- <br /> 0 <br /> ❑ ❑ ❑ <br /> r <br /> ❑ <br /> Cl <br /> ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ o _ <br /> ❑ ❑ ❑1 L <br /> n <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> �1 N�fi'1 )'° 'f l r� P� t+S•tk e �� t 7 ,F� . -- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowladge,the facia stated in ibis document are accurate and in full compliance with legal requirenunts <br /> Technician's Signature: f/ `l I'A �� '' t ' Dater f' --- <br />