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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(h1!6f?rm 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:TZ-0 6,*, In j �v do cZ � Fu e-C. Date of Testing: l Facility Address: 2 ta 5 F,a 4 2 tn�-a,t 4- S- 40 G k UYl e S ZOS Facility Contact: A4 of 1-3k C q W04hone: 3 7— 0/9 S Date Local Agency Was otified of Testing : 1 V Name of Local Agency Inspector (##present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: (� i r2an e.�.'T� S �^ Technician Conducting Test:' �.'U, Credentials: D CSLB Licensed Contractor CB.Licensed Tank Tester Lica'K I e- License Number: Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS No t Repairs Not Repairs Component Pass Fail Tested Made Component Pass Fall Tested Made wwwtl�tt.� t `4..*�1 2 s3 ❑ ❑ f� .51.1 "F'Cv u..w•. '}Z 0 0 ❑ El ❑ ❑ 1�-Stl �: e ' 3 El ❑ ❑ 0 ❑ ❑ ❑ Sect. f .Z D ❑ 0 ❑ D 0 ❑ ❑ o ❑ e d r � ❑ El D El D 0 11 1 ❑ ❑ ❑ ❑ t: r, A L D ❑ ❑ A� ❑ ❑ ❑ ❑ ❑ D r� ❑ ❑ D ❑ u Liz ❑ 0 0 p ❑ ❑ D u� 3�� ❑ ❑ ❑ ❑ ❑ 0 ❑ uo �£� ° ❑ ° El 0 0 El El 0 El p, ❑ 0 0 rillR. ev Su .•. �u, L 0 0 isD If hydrostatic testing was performed,.describe what was done with the water after completion of tests: k u t1 S uw�c s �t 1 CERTIFICATION OF T aCE NI IIAN RESPOt a eI accuratFOR e and CONDUCTING complianceTS TESTING equirements To the best of my knowledge,the facts stated w _ pate: Technician's Signature: r.