Laserfiche WebLink
SWRCB,Janusq 2002 Page j—Of3 <br /> Secondary Containment Testing Report For <br /> This forum is Intendedfor use by contractors performingperiodic testing of EIST secondary containment systems. Use the <br /> appropriate of this form to report resultsfor all components taW. The completed form, written test procedures,and <br /> printouts from tests rfapplicable),should be provided tofaeiltry owwerloperatorfor submittal to the local regulatory agency. <br /> L FACII. TION <br /> F N Date of Testing: t <br /> Facfity I <br /> Facility ContaM 6Fha 204 3 S-1 <br /> Date 1=9 Asency Was Notified of Testing: <br /> AI of ABBY hWector Ofpresent during t g): a <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co Name: <br /> Tec um Cwting Test; <br /> C CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License 2. G N —D9 <br /> Hugh rer <br /> Mannfiwom s Tra' ' E <br /> 3. SUACKARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component pass Fall Not Repairs <br /> T Made Tested Made <br /> s <br /> `l Y <br /> if hy&ostatic testing was performed,descries what was donewith the water after completion of tests: � <br /> CER CATION OF TECHNICL4N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the beset of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: _____ Date:1 <br />