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SWRCB,January 2002 Page 1 of� <br /> Secondary Containment Testing Report Form - 2u07 <br /> This form is intended for use by contractors performing periodic testing of LIST secondary 9N'QA l W eW f,4 j�-Vhe <br /> appropriate pages of this forte, to report results for all components tested The completed form,w�iiiFW4*res, and <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: r, lee°v' Date of Testing: <br /> Facility Address: 7/ xeY� 4q" 1,q- <br /> Facility Contact: !Y 11Lf e D'! Phone: —/ SS <br /> Date Local Agency W otified of Testing: ! U <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R ? yet i lia rC r e 1 <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type:fvE/L ,C,f License Number: <br /> Manufacturer Training <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 I I Tested Made <br /> Se4.Yt�tc� pr 1 ❑ ❑ ❑ (AQC.'&t- 3 X0 ❑ ❑ ❑ <br /> / ❑ ❑ ElU,1� '#'f!'-4, ❑ El 11 <br /> S�LOH-du 3 ❑ ❑ ❑ wo e 7 ¢r ❑ ❑ ❑ <br /> rr V ❑ ❑ ❑ !A-V) .. 7 !'i ❑ ❑ ❑ <br /> S�ce� ' 5 ❑ ElEl # 1 t l Z El 11 0 <br /> El rl-tj yL40, El 11 El <br /> El 11 <br /> ❑ ❑ ❑ jr.,ti i c 1''tae -L--Z ❑ ❑ ❑ <br /> Or �� S ❑ ❑ ❑ arc ;' -j± ❑ ❑ ❑ <br /> 41 <br /> ❑ ❑ ❑ ❑ <br /> � aZ � � ❑ ❑ ❑ ❑ <br /> El <br /> ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ��51 uld5wt�yl�t�d ��cbJ�anac$ feu.1V—bQ ,.� awt t 's-� ti <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this do nt are accurate and in full compliance with legal requirements <br /> -- <br /> Technician's Signatu e: —� c,cT-�a---- r Date: .v <br />