Laserfiche WebLink
02-14-05 08:31 am From-TAIT ENVIROMENTAL 714-560-8237 T-764 P.05/06 F-670 <br /> SWRCB,.innuary 2002 Page_/ of <br /> Secondary Containment Testing Deport Form <br /> Tkis form, is maeaded for use by conrracrors performing periodic testing o,4 US7'secondary containment.ysrems. Use the <br /> appropriare pages of this form to report results for all components tested The completed form, *f r teen rrst procedures,and <br /> printouts from tests(if applicable),should be provided to rhe facility owner/operawr for submirtal to the local regulatory agency. <br /> 1. >FAMATY MORMATION <br /> Facility lv'arne: t2Ct' '�:L -"' 1 Date of Tei ' <br /> Facility Address: /'Z" 4= ' Y M LJ c— i'o[�'7'at' <br /> Fa�ciliry Contact: "Sc,L _. .r Phone: 2r e� / (1Y:�3� <br /> Date Local Agency Was Notified of Testing : <i$ 441L f'JE Io fl, <br /> Nam of Local Agency Ipspector{if present during <br /> 2. TESTING CONTRACTOR WORt17AT1EON <br /> Company Name: r Z V f i <br /> Tedmician Coneucting Test o G)�' _~ <br /> Credentials: >'CSLB Licensed Contractor >e SWRCB Licensed Tank Tester <br /> T,icme Type: A ,45P. A7A L '/u License Number: .. <br /> Manufacturer Trainine <br /> Manufactures Co o s nate Training Expires <br /> 3. SUNMARY OF TEST RESULTS <br /> Component Pass P&H Not Repairs CompORent PW Fill! Not Repairs <br /> Tested Made Tested Made <br /> -� , �6 ' / <br /> �7 aLL I / 1 <br /> if hydrostatic testing was performed,describe what was dotrt with the water after completion of tests: <br /> CERTMcATION OF TECIMCLhN RESPONSIBLE FOR CONDUCTING THIS TESTWG <br /> To the best of rty knowledge,the faros stated in this dcc uument are accuraie and in full compliance with legal requirements <br /> Technician's Signattae: �— r _ �" .., r._— .._ Datt._./ /1 ' c�- <br />