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j *CSVED <br /> SWRCB,January 2002 Page -I- of <br /> 09 <br /> Secondary Containment Testing RepolAlf-orm EA <br /> This form is intended for use by contractors performing periodic testing of UST secor ¢�mNs. Use the <br /> appropriate pages of this form to report results for all components tested. The comp � f'firocedures, 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: e i 5 0 e Y 7 I—M C.9I Date of Testing: c'1 Z 0 <br /> Facility Address: "7 0 aU 120VA A P i C krx e L Cavt t`i S iv Gc�Gf ,r- 6 <br /> Facility Contact: E)ct V, r-O c A-tvrj Phone: (;7-6 _ 1 p <br /> Date Local Agency Was Notified of Testing: F No <br /> Name of Local Agency Inspector(ifpresent during testing: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: rL aA&C Q. <br /> Technician Conducting Test: u wt y\ T- to V\, <br /> Credentials: ❑CST B Licensed enintractor SWRCB Licensed Tank Tester <br /> License Type:`T A, ,Vc, ,<<, Y License Number: CIO —1 l2,6 5-2-44 go 1 <br /> Manufacturer Training <br /> Manufacturer .Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass -Fail Not Repairs <br /> Tested Made Tested Made <br /> N u a✓Tuwtc- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Cc u.+.t 1(- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> c cru i - U R I ❑ 0 ❑ 0 0 ❑ ❑ <br /> c cc3 ❑ ❑ 0 ❑ ❑ ❑ 0 <br /> 0'- 0 ❑ ❑ ❑ ❑ 0 ❑ <br /> 0 ❑ ❑ 0 ❑ 0 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of to ts: <br /> _c)r- Se C \o�� e� 1 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in th' o meat are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: -T rP.�.� c.� <br />