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g' SWRCB, January 2002 9 u Page of Secondary Containment Testing Report Form This form is intended for use by cofttractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this fonn to report results for all components tested The completed form, written test pros fres, arxd printouts from tests (if applicable), should be provided to the facility owner, operator for submittal to the local re latog ency. 1_ FA('TT.TTV T1�T�nE2t�rArrnrr=�,��'' Facility Name: ;' �; ; osr '' °' . - - - - Date of Testing: . -= ' "I Facility Address:'�' r r p -w; - Facility Contact: Phdne:- Manufacturer Training Manufacturer Component(s) Date Training Expires Date Local Agency Was Notified of Testing 2- - G� •• Name of Local Agency Inspector (if present during testing): Not Tested ❑ 2_ TFfiTNrCn V'M A C-rn ? TTT>G'nn`,r A -rrnoT Company Name: o ` '; �; cup y 12� Technician Conducting Test: J . +°•+ ' do A J-0 L1l:Cl1JtU i;t,lracE�=! u S % RCB Lic:mscd Tanis 'i ester f [Licenseu Type: �� O``��1�License Number: Not Tested Manufacturer Training Manufacturer Component(s) Date Training Expires Component Pass �❑ Fail ❑ Not Tested ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail ❑ Not Tested p Repairs Made ❑ Component Pass �❑ Fail ❑ Not Tested ❑ Repairs Made ❑ _! El Ej ❑ ! ❑ J I 1i El `" I ❑iI ❑ ❑ ❑I ❑ ❑ ❑ r ❑ ❑ I ❑ ❑ I❑ Iz�l ❑ I❑ C I ❑ ❑ t / It hydrostatic testing was performed, describe what was done with the water after completion of tests: ------��f /t-�LJ � �..\��'``�\��_ L-- _•� r' rl � 1 i ,I /1'� i \ "Y'� � t� �'_'��_�_� 1 G'�� .L � ' � 1 Y CERTIFICATION OF TECH\ICIAN RESPONSIBLE FOR CONDUCTL\G THIS TESTING To the best of nz} knofvlet. �e, tke facts stall in {h,�s jl�rr�ypont are accurate and in full compliance with legal requirements Technician's Si;nature: ;;� �f l l -=`L� Date: � ^ �s � 2 1—, E, -21 IJ I Ej It hydrostatic testing was performed, describe what was done with the water after completion of tests: ------��f /t-�LJ � �..\��'``�\��_ L-- _•� r' rl � 1 i ,I /1'� i \ "Y'� � t� �'_'��_�_� 1 G'�� .L � ' � 1 Y CERTIFICATION OF TECH\ICIAN RESPONSIBLE FOR CONDUCTL\G THIS TESTING To the best of nz} knofvlet. �e, tke facts stall in {h,�s jl�rr�ypont are accurate and in full compliance with legal requirements Technician's Si;nature: ;;� �f l l -=`L� Date: � ^ �s � 2 1—,