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MD 1 �� <br /> Sr t <br /> APR 12 2002 <br /> SWRCB,January 2002 <br /> FiraQAH <br /> Secondary Containment TestingReport Form— FINAL DRAF��IERVICES <br /> This fora is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriatepages 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: ,-tco >i L l W Date of Testing: <br /> Facility Address: ?57 � 5, EA eves-go PA-,5 P-5 1 ALA LAI CA. p <br /> Facility Contact: N)4-(- Phone: 777 7 <br /> Date Local Agency Was Notified of Testing. <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: I--i At". S t S 1,J <br /> Technician Conducting Test: i,t-,-,c-L L ,qtr e--e 1; <br /> Credentials: ❑CSLB Licensed Contractor 4 SWRCB Licenged Tank Tester <br /> License Type: License Number: ' — j 9 <br /> Manufacturer Traimne <br /> Manufacturer Component(s) Date Training Expices <br /> 3. SUMMARY OF TEST-RESULTS <br /> Component Pass Fail , Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ppf'004 5111so :, a 1,01, C ❑ ® ❑ ❑ ❑ <br /> 1 1-45"11rwLFly Stc++t 1� `❑' OT. L1 �3•- Ss� uu t=t�z 5u,s�{' ® ❑ L7. El <br /> �04 -%?fit I- !�Fttt f 4C�-F ®'...❑ ;o- 11 t 3 `a7 rte.e 5piczei e N ❑ ❑ Lj <br /> [- 97 4T /da'.-uts►2 5t'hc ® ❑ ❑ ❑ <br /> t[ -' 7 +gat t'�F'�rs ScA,�,�+ •. ® ❑ ❑ <br /> ❑�--�' ��4# —REli gut r• ii�'e� C ❑ <br /> d2-t7 �AA;L F 'AL 5 �+ Q ❑ ❑ -=---I uNc F1 Li- SciMP f1] ❑ ❑ ❑ <br /> *2-2' wrui., 5?° tt 4eu er-, a ❑ ❑ ❑ Q4 -91 Flt(- 5?/a o� r- 9 ❑ ❑ ❑ <br /> *2-V rp,C--Z, 1 i a ❑ ❑ --q( A.VAIqis a ❑ ❑ a <br /> SEGuul A l'/t'E. ;',_ ❑ ❑ ❑ `! r>� SFC /Jr �iPc ❑ ❑ ❑ <br /> 5 ic�wt>A r't.6 11 11 a ❑ ❑ ❑ ❑ E <br /> ?,P6 W ❑ L ❑ ❑ ❑ ❑ ❑ <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 /> Technician's Signature: Date: `2. ` 62 <br />