Laserfiche WebLink
` <br /> SWKCB, January 2002 Page of <br /> Secondary Containment Vesting Report Form <br /> Tl:is faun is intendedfor use by contractorspelformingperiodic testing of USTsecondary 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 (!f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> r <br /> Date of Testing: J(j / �b Y <br /> Facility Nam <br /> Facility Address: I <br /> Facility Contact: G' r Phone: <br /> Date Local Agency Was-Notified of Testing <br /> Name of Local Agency Inspector (if present during testing): S r / n A /Sr <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comnanv Name: 4__ 1-."r <br /> r1- <br /> Technician Conducting Test: Zl ,o <br /> Credentials: ❑CSLB Licensed Contractor tR-SWRCB Licensed Tank Tester <br /> License Type: . License Number: Cl- <br /> Manufacturer <br /> Manufacturer Training <br /> Manufacturer Component(q) Date Training Expires . <br /> 3. SUMNIAR V OF TEST RE LTS <br /> Not RepairsPass Fail Not Repairs <br /> Pass Made <br /> Component Comp onent Tested Made <br /> Fail Tested <br /> X ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> D � cl ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> -rOj❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 compliance with legal requirements <br /> J / ! Date: <br /> Technician's Signature:/✓% ' !/ / <br />