Laserfiche WebLink
Feb 07 05 01 : 03p Aff—da-Test (209' 794-0112 p. 6 <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing'Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondmy conuoinment 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 /> c Date of Testing: <br /> Facility Name: c Ss ! <br /> Facility Address: 1 vkn <br /> Facility Contact: Phone: — <br /> Date Local Agency Was otified of Testing: n/ D D v <br /> Name of Local Agency Inspector(is -(fp60 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comnanv Name: A <br /> Technician Conducting Test A/ .p t/tir <br /> Credentials: ❑CSLB Li ensed Contractor WRCB Licensed Tank Tester <br /> License Type:. License.Number: �� 7 <br /> Manufacturer Trainin <br /> Com onent(s Date Training Expires <br /> Manufacturer <br /> 3. SiMv!Ac`V OF TEST RESULTS <br /> Not RepairsPass Fail Not Repairs <br /> Tested Made <br /> Component Pass Fail Component Tested Made <br /> ❑ ❑ ❑ <br /> "7 - : It [ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> � ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ a ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICL4N RESPO SIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledb e,the facts stated in ilcls docun:e� are aceu`rate and in full compliance with legal requirements <br /> f t <br /> Technician's Signature: ,r l Date: <br />