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07/22/2009 14:13 FAX 209 744 0116 1� ,' g" �P!. j00001/00060 <br />(( VI <br />JA 2 2 2009 <br />SWRCB, January 2002 Page I of <br />SRN J'J�',t_lUiiV OOUNTf <br />a- , <br />Secondary Containment Testing R� _�- <br />This form Is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: p y cam` -ty' ,( CV Date of Testing: ZZ <br />Facility Address: D I Ge. S-� G" V4--QY Lt.) 61 0 C, iIL ,.: s •lrt , a 5 -2-6,�:, <br />Facility Contact: s w q✓ of vi Ae,-0 <br />Phone: Zt? p 7 - l} <br />Date Local Agency Was Notified of Testing: S ZZ v <br />Name of Local Agency Inspector (present during testing}: <br />2, TESTING CONTRACTOR INFORMATION <br />Company Name: <br />Q, --P <br />,7. 1 <br />Technician Conducting Test: LAN? <br />v r -f -c ;rt ; t ; <br />Credentials: 11 CSLB Licensed`Contractor <br />WRCB Licensed Tank Tester <br />License Type:`} Gv, �T�S-� . <br />License Number: o-1 t�,. U <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />V❑ <br />❑ <br />❑ <br />o <br />o <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />fail <br />Not <br />Tested <br />Repairs <br />Made <br />Z <br />V❑ <br />❑ <br />❑ <br />o <br />o <br />❑ <br />❑ <br />ScLar c1� 121�- <br />❑ <br />❑ <br />❑ <br />11 <br />❑ <br />❑ <br />❑ <br />SP, z <br />❑ <br />❑ <br />❑ <br />o <br />o <br />❑ <br />❑ <br />i.7.- <br />0 <br />110 <br />11 <br />El0 <br />0 <br />{ #jL�- <br />D <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />� aC <br />❑ <br />❑ <br />❑ <br />11C1 <br />11 <br />El <br />L/ <br />✓ L <br />r <br />❑ t <br />❑ <br />❑ <br />❑ <br />Cl <br />❑ <br />❑ <br />A <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />Cl <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />lY�- 4-/I.i A fu !f r1?lr to e4 feCt3A-,r.t4 re- te,fe l)V /-C Efl Ld4.s.P/tfes?"-s Pr, S -f &-- <br />CERTIFICATION <br />- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this ument are accurate and in full compliance with legal requirements <br />�A <br />Date: <br />Technician's Signat .� <� 22 <br />