Laserfiche WebLink
IDI <br /> SWRC&,4-anuary 2002 Page of <br /> ` MAR 1 0 2008 <br /> Secondary Containment Testing Report Fg <br /> Thisform is intended or use contractors a ormin eriodic testing o UST seconds contai !R ��v a�� f��T A <br /> .f .� b1' P � gP g .r ry �0 he <br /> appropriate pages of this form to report results for all components tested The completed form, written test p`roce alt s, and <br /> printouts from tests(if applicable),should be provided to the facility awner/operator for submittal to the local regulatory agencj�,:-- <br /> 1. FACILITY INFORMATION <br /> Facility Name: rl,- ekL f Date of Testing: 3 3 <br /> Facility Address: '100C> M14 . J 4 t.-W-C,h COW c ef <br /> Facility Contact: ®y- t`2 r Phone: ��_4M 3 <br /> Date Local Agency Was Notified of Testing: z'7' Ug <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JZ t° J) L'cyw.0 ,m,,c¢ -rle S 'C- <br /> Technician Conducting Test:"�e,,`Q�,,,,�ito e* A <br /> Credentials: ❑CSLB License Contractor WRCB Licensed Tank Tester <br /> License Type: ''(.,e K ,P. y License Number: <br /> Manufacturer Training <br /> Manufacturer -Component(s) Date Tramin <br /> Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Paas Favi Not Repairs <br /> Tested Made Tested Made <br /> Vt"LA V 14- ❑ ❑ ❑ 1El ❑ El 11&Iuletr CaM ❑ El [I ❑ 0 ❑ ❑ <br /> Scc L i � 0 ❑ 0 ❑ ❑ 0 0 <br /> etr 1 , . 0 0 ❑ 0 ❑ ❑ 0 <br /> SIP-Of M4 1A V A i *!6 ❑ ❑ 0 ❑ 0 0 ❑ <br /> P�IVI J&W J Pi 0- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i iYt ❑ 0 ❑ 0 ❑ 0 ❑ <br /> El 11 <br /> 0 ❑ 0 ❑ ❑ ❑ 0 0 <br /> 0 ❑ 0 0 0 0 ❑ 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 ❑ ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> U ft-lm 14,4 C*A- V4 LA S.-Q- q € <br /> r <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 infull compliance with legal requirements <br /> Technicians Signature: _� ;.. � ;, Date: Q <br />