Laserfiche WebLink
SWRCB,January 2002 *R EF age - o' ' - <br /> ` <br /> 1 <br /> Secondary Containment Testing Report For TB <br /> Thisform is intended or use b contractors performing � . <br /> f f Y p rf g per�odre testing of LIST secondary containment systems. se the <br /> appropriate pages of this form to report results for all components tested. The completed form, w (�r�� ff and <br /> printouts from tests(if applicable), shote'be provided to the facility owner/operator for submittal tcE4W4,q hg atory agency. <br /> I. FACILITY INFORMATION HEALTH DEIDARTMENT <br /> Facility Name: ?J w ,�, Date of Testing: ,, <br /> Facility Address: 35o5 O k j iV <br /> Facility Contact: f)CLV',_T�A(Jvt--C4 C, Phone: <br /> Date Local Agency Was Notified of Testing : Z U <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2 TESTING CONTRACTOR INFORMATION <br /> Company Name: j2.. T) uw t cw�c. �.. :e 5 c <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type: tL —T�5 } er License Number:70- ll�u 1"C{ +_t.5f({aj2 <br /> Manufacturer Traininu <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 11 I'1 U le,V Te.-K- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 2leaVIJ001 j W -0-1-5oul', ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 57d,rrw AA,A I ru." ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ 0 0 ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ D ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ 0 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in tl ' cument are accurate and in full compliance with legal requirements <br /> Technician's Signatur : Date: 1 <br />