Laserfiche WebLink
SWkCB, January 2002 Page �- of <br />Secondary Containment Testing Report 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 submittal to the local regulatory agency. <br />Facility Name: 5 ,,a -fir X4-1 yr, $ t Date of Testing: l 12,3 d <br />Facility Address: / SS jAj e S 4- C l at 5- <br />Facility Contact: ehl , S -lu o 4e - Phone: Zo l c? 8-_ f S <br />Date Local Agency Was Notified of Testing: l 2- 1 -7 -010.5 - <br />Name of Local Agency Inspector (rfpresent during testing): <br />i •AMM.: •; !►C •:►�-' •► <br />SUMMARY3. RESULTS <br />Component <br />-M <br />I <br />Win <br />M <br />Component <br />M <br />rA <br />Sam <br />oaa� <br />-ot�� <br />WIN <br />moo <br />0.1����I <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />9 Lj <br />13b -i u r s �',���}� <br />CERTIFICATION OF TECHNICIAN� �>iBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in tills document are accurate and in full compliance with legal requirements <br />if®1 Wd t- 83J <br />Technician's Signature: Date: <br />