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12/11/2002 WED 08:57 FAX 2098333146 MAINT & ENGINE SHOP • 91003/009 <br /> SWRCB,January 2002 Page_of. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by cor&actors performing periodic te.Jing of UST secondary cotrtainmenl yystemt. Use the <br /> appropriate pages of this forum to report reavltr for ali components testers The completed form,wr7den test procedures,and <br /> printouts from tests(if applicable), should be,provided tv the facility owner/operator for submittal to fhhe local regulatory agency. <br /> � <br /> . FACUJUAYU1WORMATION <br /> Fac Name: _ Date of Testing: V. aZ <br /> Facility Address: <br /> Facility Contacr: Phpne; O <br /> Date Local Agency Was Notified of Testing: (� <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. 'TESTING CONTRACTOR INFORMATION <br /> Corm my Name. Z�:;'na 716,1T <br /> Technician Conducting Test- --rE - r <br /> Credentials: . CSLB Licensed Cont.racror ❑SWRCB Licensed Tank Tester <br /> License Type: t 1 1j License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Ex fres <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repair Component Pass Fail Testeot d Made <br /> rs <br /> Tested Made <br /> 4fj ❑ ❑ U -- - -- ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ n ❑ ❑ ❑ ❑ ❑ ❑ <br /> D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C1 El <br /> ❑ ❑ ❑ ❑ ❑ n n n <br /> D ❑ ❑ ❑ ❑ n n n <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests: _ <br /> CERTMCATIOIN OF TECIINICIAN RESPONSIBLE FOR CO"UCTING TM TUTING <br /> To the best of rrsy knowledge, the facts stated in this document are accurate and in full compliance with legaJ requirements <br /> Technician's Signature: Date: L�oy` { 2 C-L <br />