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r <br /> S WRCB,January 2002albf <br /> Secondary Containment Testing Report FormN.6,� i 3 2006 <br /> This form is intended for use by contractors performing periodic testing of UST secondary cont ainr t, qfr1F+FG eft xl <br /> appropriate pages of this form to report results for all components tested The completed form, writte �1 G�� <br /> printouts from tests (rf applicable), should be provided to the facility owner/operator for submittal to t C- o 'U i4g 1 A <br /> igency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: /L i h i /'-f A r4- 7/ Date of Testing: 31116-6 <br /> Facility Address: .2..S -7-? S sou 4 rsar� J�isS I2d -7 a 573 <br /> Facility Contact: G i rj L Pho e: 2D9 5 3 5—06 9 <br /> Date Local Agency Was Notified of Testing : 2- <br /> Name <br /> Name of Local Agency Inspector(rfpresent during testing): lJ r <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: �, j� wtD` �ctvtc,e_Te-Sk-i vt ' <br /> Technician Conducting Test: o' y <br /> g �e.VlICctvvlV� G SJlitn,Lccv1. I', <br /> Credentials: 0 CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type: —FaK V--Te S+e-r License Number: fl)—t,12,6 <br /> . Manufacturer TraininLy <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs C o Fa. Not Repairs <br /> p Tested Made omponcrt ass i! Tested Made <br /> 11 GC u u r T�K IL't� ❑ ❑ ❑ P i , ✓ SLt..w � � ❑ ❑ ❑ <br /> f}vtttct�a` 7��crl� z ❑ ❑ ❑ � C' t Z-- ❑ ❑ ❑ <br /> ,4nv1Hla�- �f,hlL#� ❑ ❑ ❑ (AOL 5Ec. ❑ ❑ <br /> stcar7�u� #3 D ❑ ❑ Ertl /Zru+� z 0 ❑ ❑ <br /> Sc_�o���,- ►fir �`f I�]' 0 0 ❑ �;it /1_i Sem �3 ,%�.1 ❑ ❑ ❑ <br /> 5tLaY110,V,lpvQ �5 ❑ ❑ 1s"Y `t X ❑ ❑ ❑ <br /> P n u 5 Cr ❑ ❑ D s ,Ey ❑ ❑ ❑ <br /> ❑ ❑ ❑ /J U k S 6 7 £ N7 D ❑ ❑ <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 /> �r <br /> Technician's Signature: ( � �,..z-;�,+,..a�--�-� �L�,�,,,_ er,,.--- Date: 3 NA <br />