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Apr 05 05 09: 10a Carrie Brown (209) 461-6342 p. 3 <br /> Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors perforating periodic testing of USTsecondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written rest procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner,'operator for submirai to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Narne: 1 Fa ' 'ty# is Im Date of Testin : <br /> Facility Address: ,CA <br /> Facility Contact: I Phone: 'U / 3,Y- - 7777 <br /> rlato I nrwl aoanev Woe Nntifirti of Taetino <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORRAZATION 6 <br /> Company Name: <br /> Technician Conducting Test: ^ — OT Iln-tIcUle'r �. V-vCv-,TCk-,Z0I <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: )1- <br /> C!.. I License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> i - - <br /> ii <br /> 3. SUMMARY OF TEST RESULTS <br /> ' Not Repairs Not Repairs <br /> Component Pass Fail,rested Made Component Pau, Fait I rested Made <br /> ❑ 1 ❑ <br /> a <br /> a ❑ <br /> ❑ D p <br /> ❑ ❑ ❑ <br /> ❑ ❑ <br /> O p <br /> i D <br /> ❑ ❑ <br /> 0 ❑ <br /> i <br /> ❑ CIO 0 ❑ <br /> I: <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> PtKtf yyV C� ( l tlf� �C l�2 � Zr q2_ ka( C)Y� qj Spilj Ca nt'yvml <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: <br />