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Nov 12 09 04;55p � 209-367-5424 p.2 <br /> SWRCB.January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performingperiodic testing of CAST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br /> printouts from Tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:,sZleglrb Date of Testing: <br /> Facility Address: 00 Z-V Q1 S <br /> Facility Contact: � Phone: in <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: &C— "" G , <br /> Technician Conductin Test: . f j&LjgC C ED(4"4 A P...U-r <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: tj5,404�, p��'fjCZ �—t rl/L( License Number:' _j3 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 1 V 15A2S ER" R"045 A& &1Cl �! <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 6COAW P�'�' �` X ❑ ❑ C ❑ ❑ ❑ ❑ i <br /> C ❑ ❑ C ❑ ❑ ❑ E <br /> ❑ ❑ ❑ C C C D 0 <br /> ❑ ❑ 0 ❑ r ❑ ❑ <br /> ❑ ❑ ❑ 0 D :1 ❑ ❑ <br /> D C 0 ❑ ❑ 0 ❑ D <br /> ❑ C ❑ 0 ❑ ❑ ❑ <br /> ❑ C ❑ ❑ ❑ 0 ❑ <br /> ❑ D 0 ❑ ❑ ❑ 0 0 <br /> ' 0 0 ❑ D ❑ 0 C ❑ <br /> ❑ ❑ L] :1 ❑ 0 C ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature Date:_j4A4-6 <br />