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• + • � Pas - --L of 2 SWRCB, January 2002 — Secondary Containment Testing Report Form 5� This form is intended for use by contractors performing periodic testing of UST secondarv-containment systems. Use the appropriatepages of thisform to report resultsfor all components tested. The completedform,written testprocedures,and printoutsf om tests (if applicable), should be provided to rhe facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facili Name: fVO i� DateofTestmg:-2 –O Facility Address: Facility Contact: Phone: D47 Date Local Agency Was Notified of Testing: I ]Nor Tested Name of Local Agency Inspector (tfpresentduring testing): License Number: ' 3f�7– Manufacturer Training Com onent(s 2. TESTING CONTRACTOR INFORMATION Company Name: tQ An Aj rbgs7- _ Pass Fail Technician'Conducting Repairs I Made Credentials: 61 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester I ]Nor Tested License Type:f/� Manufacturer License Number: ' 3f�7– Manufacturer Training Com onent(s Date Trainin Expires Cs O S SSS 7- ❑ ❑ ❑ ❑ ❑ 3 SUMMARY'OF TEST RESULTS Component _ Pass Fail Not Tested Repairs I Made Component (Pass Fail I ]Nor Tested nepairs I Made ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ h ,, ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ 1 ❑ I ❑ ❑ ❑ ❑ ❑1010# ❑ ❑ ❑ ❑ ❑ ❑ ❑I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hWdTnstatic testing was Derformed. describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in tW document are accurate and in fu0 compliance with legal requirements /6J:4G Technician's Signature: /'T Date: –/