Laserfiche WebLink
SWRCB,January 2002 Page I of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor 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 /> 1. FACILITY INFORMATION <br /> Facility Name: TrA.t t t�� r� e v r Date of Testing: <br /> Facility Address: I fo I W -S 0 �;Q - <br /> Facility Contact: ,.'.'JA I Phone: <br /> Date Local Agency Was Notified of Testing. 5 2-7 Q Q/�l��r <br /> Name of Local Agency Inspector(rf present during testing): C f6 V< /L. L 14-5 <br /> 2. 1 TESTING CONTRACTOR INFORMATION <br /> Company dame: e Q Co a re <br /> Technician Conducting Test: ; - m <br /> Credentials: ❑CSLB Licensed`Contractor SWRCB Licensed Tank Tester <br /> License Type: l " License Number: `?,/)-I?Z 0 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Paas Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ <br /> t�tr�tt ' �t� A 1 ❑ El El El El <br /> u -`�- F-10 El El 1:1r ja ❑ ❑ ❑ ❑ ❑ ❑ <br /> 13 <br /> l' � � ,,' Jt ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ o ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ::ee r ?�.�.a,^•_ _��,•ate. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In ibis do ent are accurate and in full compliance with legal requirements <br /> f 9 <br /> "T'echnician's Signature��c�� ,_� � �*� � _ Date: ---- <br />