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0 • Page_Of_ <br /> ?WRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This farm is intended for use by contractors performing periodic resting of UST secondary containment systems. Use the <br /> es,and <br /> appropriate pages of thisflrcab/em 10reshould beport tsroovideld o he fac'lity Dome peratol components tested. The �for��6mittal to the orm, written local regulatory agency. <br /> primoutsfrom tests(if applicable), P <br /> I. FACILITY INFORMATION <br /> Date—of <br /> Facili Name: / C o & 00 3"Ck7DN <br /> Facility Address: O Uti% °^ Lv a phone: 40,7- 6 4/% 3335- <br /> Facility Contact: . r A L, k A 4 <br /> Date Local Agency Was Notified of Testing: g2ej /1 Y/ D - /9t LQ <br /> Name of Local Agency Inspector(ifpresem during testing): Ove <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com any Name: A111s <br /> Technician Conducting Test: / <br /> Credentials: CSLB Licensed Contractor L'.censeSWRN Licensed Tank Tester <br /> 6 <br /> License Type: 5 License Number: ;L" - (? ?6 <br /> Manufacturer Training Date Trainin Ex fires <br /> Manufacturer Com onent(s <br /> �e G <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> 6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 10 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ fl ❑ ❑ <br /> ❑ ❑ ❑ D ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> t! G eLld•' 6 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: <br /> (�,- C'l y1 «lam Date: 12 ' O` <br />