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of <br />SWRCB, January 2002 'Page <br />Secondary Containment Testing 4eport Form <br />r <br />This form is intended for use by contractors performing pe !odic I testing of UST secondary containment systems. Use the <br />appropriate pages of thisfonn to report results for all components tested The completedform, written testprocedures, and <br />printouts from tests (#"applicable), should beprovided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FACELJTY INFORMATION <br />ID fTesfin&-_3-,3-Z4j/ <br />Facility Name: _j ale,_ o <br />Facility Address:1 g-1 7- <br />Z <br />Facility Contact, 14-e Phone: o <br />Date Local Agency Was No of nR <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR MORMATION <br />Company Name: Franzen -Hill <br />Technician Conducting Test: ^,&e- , - t 40 <br />Credentials: E CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Number: 304147 <br />t �rr Kainin <br />Date Training Expires <br />CERTIRCATION OF TECBMCUN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this document are accurate and in full compliance with legal requirements <br />Vzo <br />Lo <br />Technician's Signator Date: <br />IV :D <br />AUG 12 2011 <br />SAN JOAQUN COUNTY <br />ENVIP,ONMENTAL <br />HEALTH DEPARTMENT <br />.. r , �� , � ��� moa <br />- - - - - - - - - - - - - <br />if hydrostatic testing was performed, describe what was done with the water after COMPIctiOn Of tests: <br />CERTIRCATION OF TECBMCUN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated In this document are accurate and in full compliance with legal requirements <br />Vzo <br />Lo <br />Technician's Signator Date: <br />IV :D <br />AUG 12 2011 <br />SAN JOAQUN COUNTY <br />ENVIP,ONMENTAL <br />HEALTH DEPARTMENT <br />