Laserfiche WebLink
Page f <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report orm <br /> This form is intended for use by contractors performing periodic testing of I-ST secondary containment systems, ( se 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 submittal to the local regulatory agency. <br /> 1. FACILITY LNF'C1ILMATION <br /> Facility Name: r r Date of Testing: Z <br /> Facility Address: t 20 Frc n Ic - "t t'c' . <br /> Facility Contact ( e rvyc�r Phone: <br /> Date Local Agbncy Was Notified of Testing <br /> Name of Local Agency inspector(if present during testing): 'On FI oe- <br /> Z. TESTING CONTRACTOR INFORMATION <br /> CompanyName: <br /> Technician.Conducting Tem <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:C57, B, C61/A40, HAZ A HIC C1 License Number. 220793 <br /> Manufacturer Tralrsirt& <br /> Manufacturer Ca one s Date Training E fres <br /> ^ tl <br /> 3, SUMNLARY OF TEST RESULTS <br /> 144 Not Repairs <br /> Component Paas Pall Tested RMaa Component Pass Fail Tested Made <br /> t <br /> d <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 4 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stared in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: -- __ _ Date:_® 1._ _ <br />