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SWRCB,January 2002 Page of <br /> Seeoludar�; Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of UST secondary 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 regular*agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: w" 05 4 to I Date of Testing: Zl to <br /> Facility Address: ( p 50k.3, ►[SDvl Wa 6G . -2-0 5- <br /> Facilityy Contact: L4,vj Y%e n r Q F1 V Phone: a-7,0 Z.57 <br /> Date Local Agency Was Notified of Testing . 12-11 ? t U <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: [L D i atAc-4. -'°'s4- L <br /> Technician Conducting Test:'-31 e,L Qvn1 i^ F' LtK C kvt TV' ' <br /> Credentials: ❑CSLB Licensed Contractor XWRCB.Licensed Tank Tester <br /> License Type: - (ew IG. T-C g ,e-K License Number. 0-t t uo <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> NotNot Repairs <br /> Component Pass Fail Tested RMades Comepairponent Pass Fail Tested Made <br /> �.� t4l � ❑ ❑ ❑ W Pc: � ❑ ❑ ❑ <br /> 11 El <br /> El 0 <br /> 1 Z ❑ ❑ ❑ (� L #` c ❑ ❑ El1 <br /> ❑ ❑ ❑ u.C1L � ❑ El ❑ <br /> etcn.�c`n.� t [IEl ❑ ,'t1 iS�l< Sw� 1_ ❑. El El <br /> C i IL-5 ❑ ❑ El I'M l e 500 S O-Z 0 ❑ D <br /> eccavt c�q ❑ ❑ IPIAI iSe..ir Sum i�+► ❑ ❑ ❑ <br /> Se��►d�w P11ElEl ❑ Li ❑ ❑ ❑ <br /> El <br /> If hydrostat' testing was performed,.describe what was done with the water after completion of tests: <br /> �l TtS� a Ge l'. r/✓7``/'-It �S� u/ 0 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> t ocument are accurate and in full compliance with legal requirements <br /> To the best of my knowledge,the facts stated In <br /> �. Date: <br /> Technician's Signature t"' t <br />