Laserfiche WebLink
SWRCB, January 2002 <br />I a6u UL <br />' <br />'Secondary Cont ' ent 'Testing Report For <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 />1. FACILITY INFORMATION <br />Facility Name: K, q, , IDate of Testing: 7 / 3 —p <br />Facility Address: t^-' r 4mol, o CIO, I <br />Facility Contact: I Phone: --7- <br />Date Local Agency Was Notified of Testing : -7- Q <br />Name of Local Agency Inspector (ifpresent during testing): <br />7 rrcrrnv0'rnNTR A rTOR iNF'ORMATION: <br />can:�en� e�xr nu rr"ugr' DVQT.TI.TO% <br />Com poComponent <br />MMM�', <br />■ <br />���j <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />K) ake r j �P 1,4 s W c. F 6 er o ft '-/ <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, tide facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's <br />Date: <br />