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SWRCB. January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION _ Facility Name: L m , t Kc.:�:-7' I Date of Testing: -7 /z- Facility zFacility Address: !25 =C►�J t� -IZ -tv�b 0/>l-A!oC f4, Facility Contact: Phone: _Q$z-c oI.z Date Local Agency Was Notified of Testing: z Z a Name of Local Agency Inspector(irpresent during testing): _` -� <e-)u i 2. TESTING CONTRACTOR INFORMATION Company Name: Champion Precision Testing.Inc. Technician Conducting Test: A)L`5 ,ti L Lf I L R a A,-� C-L Ct'G*(z F-t,,zP Credentials: X CSLB Licensed Contractor El SNORCB Licensed Tank Tester License Type: D-40 License Number: 804890 Mamrtacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component P� Fail Not Repairs ted TesMade Tested Made lc L �7i�.c iso ❑ ❑ 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ` t(E5E'2- FrLc. /3OX 0 ❑ 1 ❑ ❑ ❑ I ❑ ❑ c It Frc..c iwox ❑ ❑ ❑ ❑ ❑ ❑ ❑ c< <( V,4 em 6Q ?c ❑ Y ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Lj ❑ E. C ❑ ❑ if hydrostatic testing was performed,describe what was done with the water ager completion of tests: �1 L L dna)c.-537 F.4-1&FP sC-49F�; /C0 CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of mp knowledge, the fads stated in this document are accurate and in f ull evmpliance with le„al requirements Technician's Signature: �e�- �� 2� — Date.