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• S' • <br /> ' SWRCB,January 2002 <br /> Page_of <br /> Secondary Containment Testing Report Form <br /> 777!sform is intended for use by contractors performing periodic testing of UST secondary containment systems, se the_ <br /> appropriate pages of this form to report results for all components tested The completed form,xrdtten test proe4res, aril <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local re at <br /> 1. FACIT,I'rV INFORMATInN _ Y <br /> Facility Name: <br /> �L '4 Date of Testing: co I <br /> Facility Address: b 70 rm --! <br /> Facility Contact: M:r- <br /> Pb <br /> 42 <br /> Date Local Agency Was Notified ofTesting : 8 P D <br /> W <br /> Name of Local Agency Inspector(if present during testing): �— <br /> 2. TESTLNC CONTRACTOR INFORMATION <br /> Company Name: r -- ' SG \ 2 <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor L SWRCB Licensed Tank Tester <br /> License Type: n) 4 a License Number: <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Expires <br /> Lv 0 r o ;f <br /> L� <br /> 3. SUMbLARY OF TEST RESULTS <br /> Component Not <br /> IPass rl (Tested Repairs <br /> Component Pass Fail Not Repairs <br /> Tested , ade <br /> CA I 1 7 ❑ ❑ ❑ ❑ ❑ <br /> fvyrN C j - ❑ ❑ u ❑ <br /> unt A C = j ❑ ❑ <br /> u lg"0 - El <br /> ❑ - <br /> ❑ j 0 ❑ <br /> _ C <br /> Xf ET <br /> Hca t� ar = ❑ - ❑ ❑ ❑ ❑ <br /> p' ❑ ❑ ❑ <br /> ev oda _ ❑ _ ❑ ❑ n f ❑ ❑ <br /> If hydrostatic testing was performer'. describe what . as done with the water after completion of tests: <br /> �f��"�l l �(\ '•�.�.\,� —' �r { (�I t �' r� t � 'r �-c ('+`C C\ �c �l 1 r n rr`� <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTLNG THIS TESTLN G <br /> To the best of my knowledge, the fr,is stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:4l/ `Z B �_ Date: % d2 <br />