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SW,CB, January 2002 <br />Page i of Z <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary conuumne {g,%sj a, r. f <br />appropriate pages of this form to report results for all components tested The completed form, written test proc22 <br />printouts from tests of app[icable), should be provided to the faeillty owner/operator for suhminai to the local regulatory agency. <br />1. FACILITY WFORMATiON <br />Facility Name: e, H kAr5ee VCta rJ Date of Testing; g (2$ p <br />Facility Address; ;5pS W CV4R2TFrrC WA44Sracl<TaAj C4 <br />Facility Contact: I phone: <br />Date Local Agency Was Notified of Testing: g a <br />Name ofLocal Agency Inspector (rf presem during tesang) <br />2. TESTING CONTRACTOR INFORMATION <br />-- . 1111:: I .. I�i♦ `- k _ � � <br />111.CSLB LicensedC-0-w=or 0 SWRCB Licensed 1. <br />Tester <br />Tr2iW <br />1' <br />.111 IY. 1 I .Y 1111 1 .1111 <br />Date TrainingExtures <br />3. SUA MARY OF TEST RESULTS <br />Component <br />Paas <br />Fail <br />l Na <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fat <br />Not <br />Tested <br />Repsin <br />Made <br />If R6-- Sohl 4' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />(L **Z [LL5 SP1Ci d0/ <br />❑ <br />❑ <br />❑ <br />J <br />❑ <br />t K � 4aP SPnl. PYcX <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />� ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑i❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />C <br />C. <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ I <br />❑ <br />❑ <br />❑ <br />❑ <br />E. <br />El <br />C1 I <br />o <br />10 <br />❑ <br />1:1 <br />❑ <br />❑ <br />❑ <br />❑ <br />C <br />Cl <br />Cl <br />C <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑I <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water a$er completion of tests: <br />CERTIFICATION OF TECIMCLV4 RESPONSIBLE FOR CONDUCTING TSS TESTING <br />To the best of my knowledge, the facts .crated in this document are accurate and in full eampliance with legal requirements <br />Technician's Signature: Lac' elf Date: <br />