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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is in d for use by.contractors perfomia;gperWic testing of UST secondary containment systems_ Welke <br /> appropriate pages ofthis form to report rmsultsfor all components tested. The r omplesed form,amen less procedzwes,and <br /> printouts from.tests Cifapplicable),should be provided to the facilityownerlop.erator for submittal to the local regulatory agency.. <br /> 1. FACILITY INFORMATION <br /> Facility Name: L o Co;d- C.i Date,o€'Testing. <br /> Facility Address, z uJ a+ o. S_� i C A . )952-To <br /> Facility Contact: 4.jA L JLoo ri"i— Phone 3 - O 3 <br /> Date Local Agency Was Notified of <br /> Name of Local Agency Inspector Cifpresent&ring ieshng): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> .CompanyName: t() (om 1 c Zes tin, <br /> Technician Conducting Test_l r_,..°u,w l ,,� i-• wv1 C a4ll S(. <br /> Credentials: U CSLB Licensed Contractor . WRCB Licensed Tank Tester <br /> License Type:TA-vi G--T-,L-S ay License Number_ `jARoom <br /> &nu&clurer T aft6g <br /> Manufacturer Co nen s Date Tminin a irss <br /> 3. SUNEVURY OF TEST RESULTS <br /> Campo P Fail Net airst p Fsit get pwpalft <br /> Toted a Tested Awe <br /> Ab <br /> �-- <br /> y c <br /> 1MYL pipe H-3 <br /> f 2- <br /> 1 <br /> Ll C.. -3.f -f -I D <br /> If hydrostatic tcs!inF was performed,describe what was done with the water after completion of tests: <br /> iCdre, _ 12 s'6 favtee <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING T WS TEST*G <br /> To the best of may fasts A aed ara�lrig atre =d in fuff compliance with legal requirements <br /> Technician's Signature. ,,w Date:-_ 105 _ <br />