Laserfiche WebLink
SWRCB, January 2002 page 1 ofrT <br />Secondary Containment Testing Report Form <br />This f0M s intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (tfapplicable), should be provided to the facility owner/operator foruZtmittal to the local regulatory agency. <br />1. FACIIdTY INFORMATION <br />FFacility <br />Name: ,r c, O £ . @ Date of Testing: Z 2 3 () <br />Address: , C „t - -v C- iL r <br />Contact: i _ phone: _ —015 <br />cal Agency Was Notified of Testing: t Z v 10 <br />Name of Local Agency Inspector (tfpresent during testing): ;I <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ®w e e sZ ".� 1,• <br />Technician Conducting Test ,01 V, - t � -•y ' <br />Credentials: L CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type Taws 4C- License Number( -11BGG S�2• v 48 to2 <br />Manufacrer Trainigz <br />Manufactarer tu <br />Co s Date Tmining Expues <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />` ! <br />Technician's Signature: ..- U-- Date: It Z l �3 � 06 <br />9T00/Z00012 9TTO V6L 60Z XVA 6£:TT 60OZ/ZO/TT <br />3e <br />SUMMARY • OF 'TEST RESULTS <br />Component <br />LtG4a✓- i L <br />e Baa <br />;;�_� w: <br /><7z <br />i✓t t Z <br />V12 d.. 4 <br />pass <br />Favi . Nowt �Made pai Component <br />❑ ❑ ❑ <br />0 ❑ 0 <br />D D ❑ <br />❑ ❑ D <br />❑ ❑ ❑ <br />pass Fail <br />❑ ❑ <br />10 101 <br />0 ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />Not <br />Tested <br />❑ <br />a <br />❑ <br />a <br />D <br />❑ <br />Repairs <br />Made <br />❑ <br />a <br />0 <br />❑ <br />D <br />D <br />❑ <br />D ❑ 0 <br />0 1 <br />❑ <br />0+10-t <br />0 <br />01 0 D <br />fll <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe <br />what was done with the water after completion of tests: <br />-T--s uE�.SK11-0�fe, <br />-P- C. jvr raErse QA �i Co si"� eT%sfwsr <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />` ! <br />Technician's Signature: ..- U-- Date: It Z l �3 � 06 <br />9T00/Z00012 9TTO V6L 60Z XVA 6£:TT 60OZ/ZO/TT <br />