Laserfiche WebLink
California Secontry Containment Testing R%ort Form <br />This form is for use by contractors performing periodic testing of UST secondary containment systems. The completed form, <br />written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal <br />to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing: <br />Facility Address: ij3 '—, C_ <br />Facility Contact: 120W 101x-rlzizS <br />Phone: _ 7d — <br />Date Local Agency Was Notified of Testing : a& <br />Name of Local Agency Inspector (:fpresent during testing): S-t-svemci <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: C <br />Technician Conducting Test: 6 C, <br />- ey,L,y <br />Credentials: D CSLB Licensed Contractor <br />WRCB Licensed Tank Tester <br />License Type: <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />s <br />3. SUMMARY OF TEST RESULTS <br />Component <br />I/ r <br />0000 <br />onoo <br />©oc�o <br />0000 <br />a©oma■ <br />onoo <br />moo. <br />o000 <br />: <br />■�'a <br />aoo■a <br />- - <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN 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 />Technician's Signature: 1`93 e <br />Pape 1 of 7 <br />Date: }t—( O3 <br />1/1312003 <br />