Laserfiche WebLink
• • Page 1 of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> apprapr. to pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> appro ria om tests(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> printo1. FACILITY INFORMATION Date of Testing: Tj 2 0 <br /> FaciliTy Name: �� q 5 <br /> Facility Address AO d 1e 3 Phone: 7-AA O L � d 3 8 <br /> Facility Contact; T� r Gln e Le <br /> Date Local Agency Was Notified of Tasting: L L C) <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 17 i tw`c ¢— Sri 5 r✓ <br /> ,L..c. <br /> Technician Conducting Test. .w�ati•^eve ICCB Licensed Tank Tester <br /> Credentials: ❑CSLB Licensed ontractor License Number: <br /> License Type. l� e� �.Y'' <br /> Manufacturer Trainine Date Tra E Ex ices <br /> Manufacturer <br /> Com onent s <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Not Repairs Component Pass Fail Tested Made <br /> Component Pass Fail Tested Made <br /> [3 ❑ El [Ilwv�ru��� El El 11 [3 <br /> ❑ ❑ ❑ <br /> ❑ EJ ❑ [10 El Elc.6m< " Z ❑ El El [1 <br /> ❑ ❑ ❑ <br /> 0 E01 01 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of to s � r <br /> .0 e <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated i document are accurate and in full compliance with legal TU requirements <br /> Date: Z i `." u <br /> Technician's Signature:4 <br />