Laserfiche WebLink
Aa�au. vwvvaAavva Aviv j U I <br />SWR('i;, January 3002 Page I of, - <br />Secondary Containment Testing Report Farm <br />This <br />_PI•1n is intended for use by contractors performing periodic testing of UST secondary containment syrle»rs, Use the <br />aphrc+ta•irrtc pages of this form to report results for all components restect. The completed firm, written text procedures, and <br />prininulsf►'otn tests (if applicable), should be provided to the facility oirnet/operator for 8iihmitial to the local regulatory agency, <br />1, FACILITY INFORMATION <br />Facilit • Name; ge!o Ahs 00-1 I Date of Testing: Z <br />Facility Address: ZN 30 jej c ae A <br />Facility Contact: "O& , , ✓re Phone: <br />Date Local Agency Was Not! r14 of Testing: Zr- <br />Name of Local Agency Inspector (tfpreserri during testing); <br />Z TESTING CONTRACTOR INFORMA'T'ION <br />Company Name: ✓y <br />Technician Conducting Test: <br />Credentials: 3eCSLB Licensed Contractor <br />SWRCt3 Licensed Tank Tester <br />License Type: 4 (j 00 Z- 4- <br />Manufacturer <br />License Number: .P/153 <br />Mgpufecturer. rsiaint <br />Com nent(s) Date Training Ex ires <br />z ettmVIARV OF TEST RESULTS <br />Component C3 E"M <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />_ _ I .mad..• i "A. . t�rlA.4a et`d t'Gt �� Srle . y 4/u N+s <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To lire hest of my knowledge, th stated In Ilds docwmnt are aceorate and infill compliance with legal repiretnents <br />Technician's Signature: Dale: 7--1Z-.—&3 . <br />