Laserfiche WebLink
S W RCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended.for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(+,fapplicable),should be provided to the.facility owner/operotorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: At< o Id &1 7 2 S' I Date of Testing: 12 - 7 <br /> Facility Address: SS S . Fifa 5 <br /> Facility Contact: B Phone: -,:!541!Z-33 3 <br /> Date Local Agency Was Notified of Testing: 1/6 f//l $ i o/ - PRS f <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: d YC�-rW S <br /> Technician Conducting Test: AOAf, Pte/ <br /> Credentials: CSLB Licensed Contractor I: SWRCB Licensed Tank Tester <br /> License Type: {/ Z $ - License Number: ,3 —0190 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Trainine Ex fres <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component CF(a Tested Made Component Pass Fail Tested Made <br /> 1 eta ❑ Cl ❑ ❑ ❑ ❑ <br /> 5P6p I <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ O ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ,l Y ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> � � or » ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> q ❑ 5Z ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe 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, thefacts stated in this <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �P "-" Date:—/;, <br />