Laserfiche WebLink
SWRCB,January 2002 Page ,J—of 7 <br /> Secondary Containment Testing Report Form <br /> This,form is lirtended for use by contractors performmgperiodic testing of UST secondary comainmeru systems. Use xhe <br /> appropriate pages of tins fo»n to report results for all components tested The completed form, Wriuen test procedures,and <br /> printouts from tests(f applicable),should be provided to the facility.owner/operator for submittal to the local regulatory agency.. . <br /> 1. FACILITY INFORMATION <br /> )+acuity Name: e • L-a. DatQfTesting. d t Q (? " <br /> Facility Address: 3 3 o o 0 v C41n 1n.)-S4to c t ,6 n . <br /> Facility Contact cwt, ftTC .j:I y-u,a-k Phone 0-2 9 <br /> Date Local Agency Was Notified of Testing: UU <br /> Name of Local Agency Inspcetor( 'present d rW testing): <br /> j <br /> 2. TESTING CQNI&�&TOR INFORMATION <br /> Co Name: �, w. i c,�•�cq.,'�,�s� <br /> 'technician Condaeting Test: <br /> Credentials: U CSLB Licensed Comractor WRCB Licensed Tank Tester <br /> License Type:'�f4rb V, - I.icenseNumber. 410 --f t 2,0 <br /> iVlattufaM�urer�'rseinlug <br /> Mamii Com nen s Date Tminin Ex fres <br /> I SUIVITVIAR.Y OF TEST RESULTS <br /> Component Pass Fail 'Not Repairs Corwpeuewt P Fail Not Repairs <br /> Tested Made PUS Made <br /> Fny ] ] ] ] ] ] <br /> J d 3Wz, D ] ] ] D <br /> -?101,vt A I&ILtea- D D ] D ] ] <br /> Z D D D D D D D <br /> LAP £ q D D D D ] ] D <br /> (,•{ [,. Z E D D D D D D D <br /> D D D 1 D D D D D <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ci <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING Tt11S TEST*G <br /> To the best ofmy ksawkdge,thefoct's stated ih th' are accurate wsrd in felt compfiaace with legal requirements <br /> I,q /0 5-9 <br /> Technician's Signator : -1, .n.w G,,� Date: I / <br />