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SWRCB,January 2002 OCT 3 1 2002 Page/of <br /> Secondary Containment Testing Reporf& EN�JW DRAFT <br /> This form is intended for use by contractors performing periodic tewing of US7pf ,"8RpV4i @ynt systems. Use the <br /> appropriate pages of thisform to report results for all components tested. 77te completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility oxnerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: C01 hJ-rA K- Date of Testing: 10 - /6- 0 2 <br /> Facility Address: j 1,J, e A S G J CA <br /> FacilityContact cl S _ ,+L Phone: 1 7 ffc� <br /> Date Local Agency Was Notified of Testing: /a- //- 02 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: $ 0 KT <br /> Technician Conducting Test: u e <br /> MW <br /> Credentials: '-j CSLB Licensed Contractor IFSWRC13 Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training - <br /> Manufacturer Component(s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not R Not Repairs <br /> Tested Made airs Component Pass Fail <br /> Component Pass Fail <br /> Tested Made <br /> ❑ ■ ❑ ❑ u G 5t+.ot d 9//0 ■ ❑ ❑ 0 <br /> 4A�/144 JA ■ ❑ ❑ ❑ uOc S'otatp b I) /2 ❑ ❑ ❑ <br /> t ..✓6 12" , 4/ - >• 0 ❑ ❑ tcL Box $01-$7 ■ ❑ ❑ ❑ <br /> . tN Nu X1'2 - 93 ■ ❑ ❑ ❑ cc SP/cc t3ox t�Z 4/ C1 ■ ❑ ❑ <br /> tt✓6 RNN a3 - 9 ■ 0 ❑ 0 ❑ ❑ ❑ ❑ <br /> PIPIAJI. le.. #4 - -71- - ■ ❑ 0 0 ❑ ❑ ❑ ❑ <br /> t /A/6 */ - fs7 ■ ❑ ❑ 1-2 ❑ ❑ ❑ ❑ <br /> s A2- 9/ ■ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> N C tF 112 ' ■ ` ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> (4 2 C SumP R 3 ■ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> 4 t)c �-5UM t4 � p 1 El El 1:1 ❑ ❑ ❑ ❑ <br /> t.IDC Juwt L- 7 O M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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,the facts statedinthis document or,accurate and in fall rnmpliance with legal mq.&miaeuts <br /> Technician's Signature: " _t)�"_ Dat62- <br /> Date: <br />