COMPLIANCE INFO 2004 - 2012 - Laserfiche WebLink

Home Browse Search

SWRCB. January2002 Page of .— Secondary Containment Testing Report Form — Spill Buckets This farm is intended far use by contractors performing periodic testing of UST secondary containment systems. Lye the appropriate pages of this form to report results for all components tested The completed form, tivntten test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name:I Date of Testing: - 7_ O-/ Facility Address: j c cs f Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): Y 9 laffelfla 0 6114TN 101 ,a 10 W01 96 KV0110 Company Name: Champion Precision Testing, Inc. Tecimiciaiu Conducting Test: Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: D-40 License Number 804890 Manufacturer Trainin- Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Twit Repaad� Component Pass Fail TNotesteep a� ❑� [1 El El El El. r _1 11'D El r El t ,, ; y J ❑ ❑ ❑ ❑ ❑ ❑ �" ❑ ❑ ❑ ❑ ❑ 1-' ❑ G [I El ❑ ❑ ❑ !J ❑ E, ❑ ❑ 17 ❑� ❑ E El Ll E] IJ L1 ❑ E ❑ ❑ ❑ ❑ ❑ ❑ ❑ E. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ n ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ c 11 El L ❑ ❑ ❑ fl If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my latawledge, the fads stored in this document are accurate and in full compliance with legal requirements Date: / technician's Signature: /��G '5 � /