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DE*rO 8 2006 <br /> iWgCB January 2002 ENVIRONMENT HEALTH Page--oi— <br /> PERMIT/SERVIC <br /> �esting Report Form — Spill Buck. <br /> Secondary Containment Use <br /> Phis form is intended,fbr ase by contractors performing periodic testing of ST aecondary containment systems. e the <br /> apprmpriate pages of rl is,farm to report resalis ibr ail components tested The completed,farm. written test pmc2dures and <br /> printouts,toin tests(YJ'applicabie), xhouid be provided to the faciaiv asvnerioperator,for submittal to the farm regulatory agency. <br /> 1. FACILITY IlNFORMATION <br /> K <br /> Nam7Agcwy <br /> AddrContcal Ah of Testing <br /> f Locxror(if present during testing) <br /> 2. TESTING CONTRACTOR]TWORMATION <br /> Company Name: Champion Pir;cisitm Testing,inc. _- --- — <br /> Tecboicitm Cootmctlng Test: �� S <br /> Ctedendals: X CSLB Liter Ctmtmctor ❑SWRCS Licensed Tank Tester <br /> Litzrtx Type: D-40 License Number: SW90 <br /> MamrfatKorer Traininta <br /> Mamrfac[wer corn wut(st Dene T=Mg E <br /> -ct <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Relmin Compotreat Fos+ Pail Not Rapers <br /> Camponeat <br /> R ito pNt �l to f Te❑ed Made ❑❑ ❑❑❑ Te❑❑❑a <br /> m ID❑at <br /> e <br /> tt ❑❑ <br /> o- 1,064 <br /> ul <br /> ❑ <br /> r — <br /> ❑ u J ❑ J u <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1-7 <br /> ❑ ❑ C ❑ ❑ ClJ <br /> ❑ ❑ ❑ ❑ ❑ u <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ u ❑ <br /> ❑ L-10 ❑ ❑ r] <br /> if!rydrostazic testbtg wds performed,descfibe what was done with rite water after completion Of tests: <br /> CERTMCATION OF TECwffCIAN RESPONSIBLE FOR CONDUCTING-THIS TESTING <br /> 7'o the bew of my Aamwtedge• the fads ImOa in thts dmuttsent`u�""and u full carept"t a with legal requi meats <br /> Technician's Signatute:_ r— -- Date: <br />