Laserfiche WebLink
' Dec -21 2007 11 : 56AM HP LASERJET FAX • p. 3 <br /> • <br /> SWRC13,lanuary2002 Page I of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performing periodic testing of USTsecondary containment systems. Use the <br /> appropri<uepages ofthisform to report resultsforall components tested. The completedform, written test procedures, and <br /> printoutsfrom tests (if applicable), should be provided to the facility owner/operatorforsubmittal to the local regulatory agency_ <br /> I. FACILITY INFORNfATION <br /> Facility Name: Date of Testing: f— <br /> Facility Address: tf p y rj 6,je T <br /> Facility Contact: TGHc-L LG Phone, OG O <br /> R 702 A- <br /> Date Local Agency Was Notified of Testing: 12 - _ <br /> 0 -7 <br /> Name of Local Agency Inspector ffpresent during testing): n)byJ j5" <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: o n° Cz"-" <br /> Technician Conducting Test <br /> Credentials: WSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number Q$]Z ( S2S 2 <br /> Manuf2eturer 'nino <br /> Manufacturer Co nen s Date Ttai'—jnZ Ex ices <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fan Not Repairs Not Repairs <br /> Tested Made Component Pass Fall Tested Me <br /> W Ll El El <br /> W. ia' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C ❑ Cl ❑ ❑ ❑ ❑ ❑ <br /> W0. ❑ ET ❑ ❑ ❑ ❑ ❑ ❑ <br /> SrP Suw�P 8 D ❑ ❑ ❑ ❑ ❑ ❑ <br /> b s SSP ❑ ❑ ❑ ❑ ❑ D ❑ <br /> W D, P -4wwe V ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i/ UOVI- UDC- ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> J�llfL4&2 ,LV-2 ,j 29nn 6& 9 v <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full eonipliance with legal requimments <br /> Technician's Signature: —41hea .Z� Date: 12- -11-07 <br />