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SWRCB,January 2002 Page Z of <br /> Secondary Containment Testing Report Form <br /> Thu form is intended for use by contractors performing periodic testing of UST secondary containment systems., Use the <br /> appropriate pages oj'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 submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: VJ i Se)v UJ 014 Y'Jv'' Date of Testing: <br /> Facility Address: L4 3 N o J->m, l i S c��o 1,011,4 e G cc. • -- `4 2-0 <br /> Facility Contact: /4 r<� o v` -( �e a a 0 k-a Phone: 2 r 2 Lf 2,- Z 3qq <br /> Date Local Agency Was Notified of Testing: p 1-36102) <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: tom,, i can e ya. <br /> Technician Conducting Test: ` P-%' V-'k, <br /> Credentials: ❑CSLB Licensed dontractor �RCB Licensed Tank Tester <br /> License Type: I-c IL- '"7-es —e V License Number:. <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 /> 0t"a 1,9 V, --F ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E.;Pt, Q,y ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t r�Vc.,ges pD ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> S , `�: t ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> l� £ 2- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> U ;" 3 �6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> . ' ? t ❑ ❑ ❑ 11 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests: <br /> g <br /> 'r P E A- 4 lA$I e3 <br /> _ CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCT IN HIS TESTING <br /> To the best of my knowledge,th facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature <br /> i <br />