Laserfiche WebLink
SVl <br /> SWRCB Jan 2002 Page L of <br /> �'y <br /> secondary Containment Testing Repoit Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems, Use the <br /> appropriate pages of this form 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 sulififfital to the local regulatory agency. <br /> L. FACILITY INFORMATION <br /> FacilityName: Cvow. -20176 Date of Testing: t 1 L �3 <br /> Facility Address: 1;1._0 s n,,4A, r, .k 44— 3 <br /> Facility Contact: v, ,1A Phone: 5 l <br /> Date Local Agency Was Notified of Testing : (� <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 1 <br /> Technician Conducting Tes : 1 C- <br /> Credentials: 0 CSLB License Contractor WRCB.Licensed Tank Tester <br /> License Type: ,k4, - y License dumber: 1. .f <br /> Manufacturer TrWWpz <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made <br /> Component pass Fail Tested Made <br /> El 11 11 <br /> El 11 <br /> ❑ ❑ 1) El <br /> ❑ 13 <br /> 0 C1 <br /> ° o o ❑ ❑ ❑ ❑ <br /> ❑ ❑ o ❑ ❑ ❑ ❑ <br /> E <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ o ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ D ° ❑ ❑ ❑ <br /> If hydrostatic testing was performed,.describe what was done with the water after completion of tests: <br /> f r t&fie. <br /> CERTIFICATION OF TEaCeHNI L4,N RESPONSIBLEd In this re accurate ando full compliance HIwith STESTING <br /> ST I Nrequiremenis <br /> To-the best of my knowledge,thefacts <br /> pate: t t, «, <br /> Technician's Signatures <br /> � � <br />