Laserfiche WebLink
SWRCB, January 2002 Page / of A— <br /> Secondary Contai ent T'estinb*Report Form* <br /> This form is 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 frau tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: (` o -4 Date of Testing: , ; <br /> Facility Address: �}` t9 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: -3 - 0/ — d6 <br /> Name of Local Agency Inspector(ifpresent during testing): MNC7E r <br /> 2. TESTING'CONTRACTOR INFORMATION <br /> Com an Name: e <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Trainin:: <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUNDIARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Compo Pass Fail Tested Made Component Pass Fail Tested Made <br /> /nent <br /> (' ! 6�(1 i P ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑Xi cA ❑ <br /> !t �" ❑ ❑ ❑ ❑ <br /> ❑ 0 0 ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 0 <br /> 0 ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> V1 `e ( k? t `� <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 /> Technician's Signature: In ,�( `� Date: <br />