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ACDEH,August 2003 Page of <br /> Secondary Containment Testing Report <br /> This form is intended for use by inspection staffperforming testing during installation of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed forms,written test procedures,and printouts from tests <br /> (if applicable),shall be used in evaluating the installation of new equipment and repairs to existing equipment. <br /> 1. FACILITY INFORMATION <br /> Facility Name ;2; Date of Testing: <br /> Facility Address: <br /> Facility Contact: �Q�,- jf Phone: <br /> Date Local Agency Was Notified of Testing: / <br /> Name of Local Agency Inspector(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company U.S.T.Compliance Testing Inc. <br /> Technician Conducting Test: Tony Fontana/Bill McCarthy <br /> Credentials: x CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A Gen.Eng. #846288 License Number: <br /> Contractor's Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> In-Con TS- STS 2-22-2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ ❑ ❑ <br /> Ale, El 0 11 01 <br /> ❑ ❑ [1 11 El 11 <br /> I r ❑ ❑ ❑ ❑ ❑ <br /> 7 6-c4A—,Z, .C^ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 41 ❑ ❑ ❑ <br /> 9l coy L_s.,,� ❑ ❑ ❑ ❑ ❑ ❑ <br /> OC ��Q '�aZ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> LGOG 'x 7 '� S' ❑ ❑ ❑ ❑ ! ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Testing solution taken with us to use at next test <br /> Inspector's Signature: - Date: /,-2 <br /> R <br /> ECS <br /> DEC 19 2016 <br /> ENVIRONMENTAL HEALTH <br /> nF-PARTMENT <br />