COMPLIANCE INFO 2007 - Laserfiche WebLink

Home Browse Search

cc ' SWRCB, January 2002 f�l�``-Jl=t��t F5 Page of -] co„nndar� ("nnt�inmentu' t,'�171�eaort Form nada vu ui ('nnf. ism This form is intended for use by contractors performingper_��q� 4i�(cM kZ�ndary containment systems. Use the appropriate pages of this form to report results for all com�or�� ;tgftegE&&pleted form, written test procedures, and printouts from tests(if applicable), should be provided to the facrlrty owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION , Facility Name: a P-,-'-o -4A-.0 5 4('9 1 Date of Testing:L p t 3 d Facility Address: 13 O SDc t 4-In VJ Soin to 1�. S-�r�c-tcdtd t . d4. 5 2 0 S Facility Contact: q,,.)rLJ; 4- Phone:C 2-U4 D 12,,S- Date ,,S- Date Local Agency Was Notified of Testing : @ D I t l O Name of Local Agency Inspector(fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: 1D e,,s I n t^,c e _T- S �G..1 Technician Conducting Test:Tj eA'^ { u V, v+ F. (tvt 64. �J r Credentials: 0 CSLB Licensed Contractor WRCB Licensed Tank Tester License Type: Tej44 IL 77;il•S'f (!!4 License Number: 170-112_f) Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs T Tested Made Tested I Made ❑ ❑ ❑ (A 1 ❑ ❑ ❑ vtiicl(c't✓� IG Z ❑ ❑ ❑ C,c D� f ,U - ❑ ❑ ❑ 2... J ❑ ❑ ❑ LA d e- �-15 L 1� �. ❑ ❑ ❑ e-ro,' a ��e - ❑ ❑ 0 �� I I Li s� Su:V,P-kt I 0.. ❑ ❑ ❑ � a. fz- '.. t� ❑ ❑ ❑ ❑ a ❑ ❑ If hydrostatic testing was performed,describe what was done with the water ate/r) completion of tests: �! F1 z d 11"i' '� y �' .7 ,�i '�. ! ( '..�,di 't`. /' �-tff ( Z £ r� t i' C^:7 rr f•' f 'Y CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TMS TESTING To the best of r7y knowledge, the facts stated in this document are accurate and in full compliance with legal requirements _ � ��)��- Technician's Signature: - ( n Date: 6-!)