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SWRCB, January 2002 Page L of EP € 2 2008 Secondary Containment Testing Report Form ENAVR,,� ,,: i Thisform is intended for use by contractors performingperiodic testing of UST secondary coUse the appropriate pages ofthisform to report resultsfor all components tested. Thecompleted forrtE , � t� dures, and printouts from tests (f applicable), should be providez:4'lo the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION IJ Facility Name: 0 q4d V Ul) F'914 e v e C. I Date of Testing: 6 Facility Address: v 3,'2- 64-s-1- ,d- p v &164w C S 0 S Facility Contact: A4 L `j / Phone: Date Local Agency Was Notified of Testing : g 1'68 Name of Local Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: r y7/9; utv�c e e of Technician Conducting Test: �. r„ ' a u ; r't t C. t4 Tr' Credentials: ❑ CSLB Licensed Contractor WRCB Licensed Tank Tester License Type: lL License Number: 76-112-.Z) Manufacturer Manufacturer Training Component(s) Date Training Expires ❑ El 11 11 k-&,ylur lG#Z 3 ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Tested Repairs Made t+tn k u fQ q t:t K [1❑ ❑ El 11 11 k-&,ylur lG#Z 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ S�cav�dl aY r-�- ❑ ❑ ❑ ❑ ❑ ❑ ❑ S�caie dab �fZ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �eeucid •' 3 ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ,:, 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ (s��?47 5.jLj ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ 5f4v ❑ ❑ ❑ ❑ ❑I ❑ L ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: SC4,0DI f ed j,11, u c - ,f �w f a CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this cument are accurate and in full compliance with legal requirements Technician's Signatur _ Date: /l