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SWRCB, January 2002 • •R im 8 <br /> Secondary Containment Testing Report ForU& 032008 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use rhe <br /> appropriate ages of this form to report results for all components tested. The completed form, iaWamAMproalyjyw, and <br /> printouts rom tests(if applicable), should be provided to the facility owner/operator for submittal 19NYAFMMEhtgtlatory agency. <br /> I. FACILITYINFORMATION HEALTH DEPARTMENT <br /> Facility Name: J Eue L S Date of Testing: Z 0 <br /> Facility Address: Z {3 Z3 1Ju/ 4W,4j ( "'t O �C , c� 2 Z U <br /> Facility Contact: &clll iAe sl�4rr I 0 Phone: CLOD ILL ZUfo <br /> Date Local Agency Was Notified of Testing: ( (( t 013- <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 1 w S cl c c Te g i v <br /> Technician Conducting Test: a u , ; tkJ Ga v. TY' <br /> Credentials: ❑CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type: 5 W (LGj5 `rtlCS (�Y License Number: O I I ZU `E U60 Z-to <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> "LA IeA �Kh*y ❑ ❑ ❑ p C � 71 F ❑ ❑ ❑ <br /> Se1o✓t�u. t �. ❑ ❑ ❑ *� 9 t l6 ❑ ❑ ❑ <br /> ecd"Aa6, "10-**a ❑ ❑ ❑ Lt k� ( I rlL ❑ ❑ ❑ <br /> e c rl 12P I'3 ❑ ❑ ❑ I(A Q -0 1301-f 11./ ❑ ❑ ❑ <br /> Scco u� ❑ ❑ ❑ LA D l S c. 1 h ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V+ S w,. *L J 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tM SV, ^ ) I' 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ,� ) ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> U lrL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> U f> Lir 3 r i ❑ ❑ El El ❑ ❑ ❑ <br /> If hydros tic testing was performed,describe what was done with the water after completion of tests: <br /> Pros,e,-KJ 7.— let4je b / /-_j 3V E Oi,—!1 Iirc:mr4 rJ rD ! <br /> CERTIFICATION OF TECHNICIAN RE�PONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated In this docyment are accurate and in full compliance with legal requirements <br /> Technician's Signature (�/ _ > � ^ ' " Date: ( 12 O <br /> � NV <br />