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SWRCB, January 2P02 • • Page I- of c� Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and printouts from tests (f applicable), should be pros ided to thefacility owner/operator for submittal to the local regulatory agency. 1. FACYLFPY TWORMATinN Facility Name: O t' S M et PJY Date of Testing:/2,7 616 cat Facility Address: �tt Li H J etn �Z Facility Contact: S'a , 6fv[ ^ i �j rZH / Phone: 2D ey -s Date Local Agency Was Notified of Testing: 2 1) 8 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING rONTRACTOR TNTinRMATMAX Company Name: 7 ---- Technician Conducting Test: / may,,, Credentials: ❑ CSLB License Contractor CB Licensed Tank Tester License Type` —A� /G f Manufacturer ✓ License Number: ®/ / . 0 Manufacturer Training Component(s) Date Trainin Ex fres 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowlecig 411 facts stated in this ment are accurate and In fuU compliance with legal requirements Technician's Signator . y v... w - �. Date: U i 0 rTWEIMO : Om0 ° o0o anon mom. noo onoo 0mm0 rrAft If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowlecig 411 facts stated in this ment are accurate and In fuU compliance with legal requirements Technician's Signator . y v... w - �. Date: U i