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Fels 02 10 10: 04a Elite T V Contactors <br /> 12094G;6342 <br /> SWRCB,January 2002 Page I of <br /> Secondary Containment Testing Report Form <br /> Thisform is intended for use by contractors performing periodic testing of UST secondary contalrrnrent systems. Use the <br /> appropriate pages of this form to report results far all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owne)/operatorfor submittal to the local regulatory agencv. <br /> _ I. FACILITY INFORMATION <br /> Facility Name: 1 ( Date of Testing: <br /> Facility Address: ^ _ t <br /> Facility Contact: Phone: 2 IL <br /> —M <br /> Date Loea[Agency Was Notified of Testing; C' <br /> 02,010 n <br /> Name of Local Agency Inspector(zfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tabic Tester <br /> License Type:=, 't ti 1 n License Number: <br /> 1llannfacturer Training <br /> ot <br /> Manufacturer Coonent(s) Date Training Expires <br /> WWI `4F!ft)E(1QHQ <br /> ` Mt ru53 <br /> ^!Z <br /> - .1 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs _ Not Repairs <br /> Tested Niadc Component Pass Fail <br /> Testcd h4ade <br /> El ❑ ❑ ® ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ . <br /> ❑ ❑ ❑ ❑ a ❑ ❑ <br /> ❑ ❑ C ❑ ❑ ❑ ❑ <br /> HE003 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> AA hAiU , 1.001- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of my knowledge,the facts stated in this doctrrnent are accurate and in full compliance ruith legal requirements <br /> Technician's Signature: J\�11A1 fJl/U. �,L Dater SA 4 2 2 ' �� j <br />