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3 SWRCB, January 2002 <br />Page L of a <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY .INFORMA'T'ION <br />Facility Name: '&e-o,r 2 tL i S �� - —(�� Lt Date of Testing: / p U <br />Facility Address: i Z S A - r, L- (Lq S <br />Facility Contact: { l 4 E A-eA Phone: AO 3 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (1fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: S <br />Technician Conducting Test: ��,� Gt-t✓t <br />Credentials: 0 CSLB Licensed ontractor WRCB Licensed Tank Tester <br />License Type: �� License Number: 6)_-j (2-!� <br />Manufacturer Trainin <br />Manufacturer Com onent s Date Training Exnires <br />'2 CTTMMADV nv rvo r Dr. OTTT •rc, <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />r'�f U % s 7 r { (- �' CC> � ✓Ct°� - ,��GC ..� Jm �LC+f � - tot <br />CERTIFICATION OF TECHNICIAN R PONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated /n th d u nt are accurate and In full comp!lance with legal requirements <br />Technician's Signature -- ` e .. �.,.- - Date: <br />■■■■Componew, ■■ <br />■■■■Component■�■ <br />:. <br />c , . z�m��■r�oo�c■ <br />r.�oi■■■■� <br />©aa© <br />■■oa <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />r'�f U % s 7 r { (- �' CC> � ✓Ct°� - ,��GC ..� Jm �LC+f � - tot <br />CERTIFICATION OF TECHNICIAN R PONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated /n th d u nt are accurate and In full comp!lance with legal requirements <br />Technician's Signature -- ` e .. �.,.- - Date: <br />