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a u vv a. a v +u+ . +.v+.a tst.uee uut®vauuva avn I U I <br />SWR('13, .lanuary 2002 Page I of 3— <br />Secondary Containment Testing Report Form <br />This fwm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />apprrtrirlie pagev of this form to report resedis for oil components tested, rhe completed form, written test procedures, and <br />printoods.koln tests (if appl/cable), should be provided to the facility ott►fer/operator for rttbmittal to the local regulator, ugetuy. <br />i. FACILITY INFORMATION <br />Facilit Name: o �Q,w, !aw►/ Date of Testing: Z - /•-•-63 <br />Facility Address: Z.Y3er Ge: RA"t iaL �/ YdL A <br />Facility Contact: „ -4 " ✓sC <br />Date Local Agency Was Notiricd of Testing: L- tom- v3 <br />Name of Local Agency Inspector (!f presenl during lestingJ: <br />2. TESTING CONTRACTOR IN•' • <br />Company Name: ✓r1 <br />Technician Conducting Test: <br />Credentials: X CSLS Licensed Contractor <br />SWRC3 Licensed Tank Tester <br />License Type: (f 4z_ 4e <br />Manufacturer <br />License Number: l/153 <br />MAOurscturer-Tratnint <br />Corn oocnt(s Date Training Ex ires <br />s-T- <br />mom= <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />w we�,,.a% t./A.�� / �ka`.d QMOIi lG f�� S /tt MaS • ®- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To Nae hest oJ'eny knowledge, th r0®ted lit this docatttenf are accurate and infill rompilance with legal regltiretnettts <br />Technician's Signature: Date: <br />- <br />y-�WM <br />r .� <br />mom= <br />mm <br />mmmm <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />w we�,,.a% t./A.�� / �ka`.d QMOIi lG f�� S /tt MaS • ®- <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To Nae hest oJ'eny knowledge, th r0®ted lit this docatttenf are accurate and infill rompilance with legal regltiretnettts <br />Technician's Signature: Date: <br />