Laserfiche WebLink
It Page of ... <br />Secondary Co inl mut Tcsthig Report Fos <br />This form is intended for use by contractors perforating 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. <br />and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local <br />regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name:See,r.jt Ta e I Date of Testing: / z /g �_ <br />Facility Address: -7606 ; 1tvr2 X ;V.- C14 6,4, I'S �3 <br />Facility Contact: /319h V69? _ ifs, 3 7 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector Present: <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R u) eo'.,. l I T ; K <br />Technician Conducting Test`",„^ 4A."r"t r Sir - <br />Credentials: D CSLB License Contractor ASWRCB Licensed Tank "fester <br />License Type and #: S w ►Q- e r(3 Ls 4:44 12,11 <br />Training by Manufacturer <br />Manufacturer Com onent s Date Training Ex ires <br />3. SUMMARY OF TEST RESULTS <br />Number of I arks "I-estea: c--. <br />Number of Piping Runs Tested: <br />Number of Submersible Pump Sum s Tested: <br />z— <br />Number of UDC Boxes Tested: <br />Number of Fill Sum s Tested:. <br />Component <br />Pass701 <br />Number of Overfill Boxes Tested: <br />Comments <br />la 'ilu.Nte:- <br />4- z- <br />❑ <br />5 e1 eV ee 4Z' 3 <br />ell <br />s T <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />Technician's Signature: <br />SWRCB <br />Date: 12,1 ! vI® <br />Dccember 2001 <br />