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FROM :Donlee pump co. <br />5W K% -b. JanUarV LVVL <br />FAX NO. :2095379398 `ug. 29 2005 09:12RN P3 <br />robe —L— Ot <br />Secondary Containment Testing Report Form <br />7 Is form is intended for use by contractors perforating periodic testing of UST secondary containment .ryslattrs. Usethe <br />appropriate pages of this form to report results for all components tested The completed form, written rest procedures, and <br />printouts from rasts (if applicable). should be provided to the facility owner/operomr for submittal to the local regulatory agency, <br />i_ FACILITY INFORMATION <br />Facility Name: Date of Testing: <br />Facility Address: <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Nance of Local Agency Inspector (tf presenr during resting: <br />2. TESTING CONTRACTOR INFORMATION <br />Cotnpans name: <br />Pays <br />Technician Conducting Test: <br />Not <br />(Tested <br />C.redendads: 0 CSLB Licensed Contractor <br />SNVRCB Licensed Tank Tester <br />License Type: <br />License Number: <br />Not <br />Testeel <br />Repairs <br />Ai:�de <br />Nianufacturer <br />Manufacturer Training.; <br />Cont onent(s) Date Trtinintt Expires <br />3. SUMMARY OF TEST RESULTS <br />(;URlpllllCjit <br />Pays <br />Fait <br />Not <br />(Tested <br />Repairs <br />I Nla� a <br />Component <br />pita% <br />Fail <br />Not <br />Testeel <br />Repairs <br />Ai:�de <br />❑ <br />C <br />❑ <br />f -- <br />I <br />_1 <br />0 <br />0 <br />'^^1 <br />2 <br />ID <br />11 <br />U <br />f� <br />t.J <br />© <br />J <br />'_, <br />❑ <br />❑ <br />� <br />_.._� <br />❑ <br />J <br />❑_ <br />❑ <br />❑ <br />C <br />❑ <br />o <br />❑1 <br />�, <br />❑ <br />❑ <br />❑ <br />I <br />❑ <br />a <br />E <br />❑ <br />E:❑ <br />10 <br />,D <br />❑ <br />_�.. <br />L <br />E. -� <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ �.._...a <br />if h-,drostntic testing was performed, describe wltnt eras done i\ ith the woter after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CO NDi1CTING THIS TLSTING <br />7b rhe bell of nri knol�ledd e, clic facts aYatGrl itr tlris document race accurate meed in frill c'ontpliunee )with (regal rcequirenrenis <br />.1 • <br />Technician's Sigi'Wure: Datc:z—L <br />