COMPLIANCE INFO_2004-2009 - Laserfiche WebLink

Home Browse Search

01/08/2010 10:04 FAX 916 371 2380 BZ SERVICE STATION 121002 SWRC13,, January 2002 Page __ of Secondary Containment Testing Report Foram This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report resultsfor all components tested The completedform, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FAr7TjTV 11V90RMATTf1N a?aciiity Name; - - -- --- - — - - -- ---- - - Date of Testing: Facility Address; Facility Contact: Phone: C' Date Local Agency Was Noti ed of Testing Name of Local Agency Inspector (f present during testing): 1�� , 1� � i Company Name: B.Z. Service Station Maintenance Technician Conducting Test: TC -C. credentials; X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: Manufacturer Manufacturer Co License Number: 433159 Training ones s Date Training Exp )res �00 w 3. SUMMARY 4F TEST RESULTS If hydrostatic testing was performed, desoribre what was done with the water after completion of tests: �,�x .�xin 1�!"aa3 Lim �;j�r •'n�i �e Vuo J I�„k4K j ,I a '?L,-1-AA16 av, f3l +4 CERTIFICATION OF TECHNICIAN RESPONSIBLE FAR CONDUCTING THIS TESTING To the best of my knowledge, tine fasts stated in this document are accurate and Its jW1l compliance with legal requirements Technician'sSignaturef .'..�� Date:_ L�- �00 w i � . Y �-, 070 ■ 0�0 ��L mom If hydrostatic testing was performed, desoribre what was done with the water after completion of tests: �,�x .�xin 1�!"aa3 Lim �;j�r •'n�i �e Vuo J I�„k4K j ,I a '?L,-1-AA16 av, f3l +4 CERTIFICATION OF TECHNICIAN RESPONSIBLE FAR CONDUCTING THIS TESTING To the best of my knowledge, tine fasts stated in this document are accurate and Its jW1l compliance with legal requirements Technician'sSignaturef .'..�� Date:_ L�-