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SWRCB, January 2002 Page I ofa <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic 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 aw:ier/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: N )of k //,-,154y,,,,) w, ' Date of Testing: S Z 9 U <br />Facility Address: JC8 o 5-,, Af,(j%/SGtzt ��' L UY� zz S <br />Facility Contact:W�g� (,U ; _ k -t—Pone: Zp 6 — 6 G 3 <br />Date Local Agency Was Notified of T , g : /6 <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Q wN i er,,r <br />;: v, - <br />Technician Conducting Test: &C 14 W p- <br />F U C eu, T✓. <br />Credentials: ❑ CSLB Licensed Contractor <br />WRCB Licensed Tank Tester <br />License Type:"P�-4 (L e8 1/ <br />Fail <br />License Number: Q-1(2-6 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />V <br />❑ <br />❑ <br />❑ <br />; �? m .? 3 <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />,Anfor —tau 1 i. <br />V <br />❑ <br />❑ <br />❑ <br />; �? m .? 3 <br />❑ <br />❑ <br />❑ <br />IQ a��cwr 1c*2- <br />❑ <br />❑ <br />❑ <br />Su tµ <br />❑ <br />❑ <br />❑ <br />F'Ild Gl fQ' i✓ �ubl� <br />❑ <br />❑ <br />❑ <br />EL t) E <br />❑ <br />❑ <br />❑ <br />SC ccl C�1v 7Jt .1 <br />❑ <br />❑ <br />❑ <br />G( f k- <br />❑ <br />❑ <br />❑ <br />.;6rM4d&i0'11 fiae #Z <br />❑ <br />❑ <br />❑ <br />Lc i)e <br />❑ <br />❑ <br />❑ <br />cc k `3 <br />❑ <br />❑ <br />❑i.d <br />, 74 <br />❑ <br />❑ <br />❑ <br />eCove�u `� <br />❑ <br />❑ <br />❑ <br />I I / 1-,5e <br />11 ❑ <br />❑ <br />❑ <br />�Q dur <br />❑ <br />❑ <br />❑ <br />r l2es�.YL <br />❑ <br />❑ <br />❑ <br />c �r4, <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br /><eco" du, <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />2 i-, <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�rn #y <br />El <br />❑ <br />11 <br />El <br />El <br />If hydrost tic testing as performed, describe what was done with the water after completion of tests: <br />TCS u i � S � �'� � I e c ��. c p, ft,roU.� � �,Lt �..�' `� L i/ c.-C7✓v� � � f. CXR C C �,� -. �;�`°` °'( <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts statedi7is <br />documentare accurate and infull compliance with legal requirements <br />1 V rZ <br />Technician's Signature. ;c� �-- - Uate: J j <br />