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SWRCB, January 2002 ECEIJ \l EDge ) Of <br />Secondary Containment Testing'Report Form JAN 2 6 2004 <br />Ij Testing <br />Thisform is intended for use by contractors performing periodic testing of UST secondary cont 'I I z A ff the <br />9a <br />appropriate pages of this form to report results for all components tested The completedA I ures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor sublatory agency. <br />7 rxrv?f-%-n -NX A 'IrTnTT <br />Facility Name: <br />Date of Testing: 7 <br />e <br />Facility Address: AV <br />' <br />Facility Contact: Phone: <br />Date Lqcal,Agency Was Notified of Testing <br />I , Ther Artnr .1hrnrP.vPnt during testing): <br />4A. <br />aw 1F.74 V Elie I <br />Technician Conducting Test: L )0 JJ MgVkCB Licensed Tank Tester <br />Credentials: D CSLB Licensed Contractor License Number: C� --? —11'4 -!s <br />License Type: I IM -11111 11 11ENNMM=NN0WM�1 I'll <br />Manufacturer Training <br />Manufacturer Com nonentf-" Date Training Expires <br />CE I RTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />TO the best of my knowledge, the facts stated in this document are accuiate and in full compliance with legal requirements <br />a. <br />Technician's Signatur e Date: <br />3. SUMMARY OF TEST RESULTS <br />-- Not RepairsComponent <br />Component Pass Fail Tested Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />0 <br />11 <br />El <br />D <br />0 <br />0 <br />11 <br />El <br />11 <br />El <br />❑ <br />El <br />0 <br />—E] <br />11 <br />0 <br />El <br />11 <br />El <br />0 <br />11 <br />El <br />0 <br />11 <br />—0 <br />0 <br />0 <br />0 <br />El <br />—El <br />El <br />El <br />E) <br />El <br />0 <br />11 <br />—0 <br />—0 <br />El <br />0 <br />11 <br />0 <br />0 <br />If hydrostatic testing was performed, de .. scribe what was done with the Water after completion of tests: <br />CE I RTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />TO the best of my knowledge, the facts stated in this document are accuiate and in full compliance with legal requirements <br />a. <br />Technician's Signatur e Date: <br />