Laserfiche WebLink
C` <br /> ',.sr ���.-s�i ��,-•����� �� �u����� *i xt��'�� mz, <br /> Champion P.O.Box 13059 <br /> f Sacramento, CA 95813-3059 <br /> Precision Tank Testing CA 800-600-9443 <br /> ticense No.118724 NV 800-949-9443 <br /> (916) 927-1557 <br /> gC-�--c-�,✓I FAX: (916) 927-7345 <br /> "'-' <br /> e.i <br /> Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use <br /> the appropriate pages of this form to report results for all components tested. The completed form,test procedures,and <br /> printouts from tests(if applicable),should be provided to the faci'rity owner/operator for submittal to the local <br /> regulatory agency. <br /> 1. FACILITY INOFORAIATION <br /> Facility Name: Date of Testing: <br /> Facility Address: ;?el, <br /> c cc t. <br /> Facility Contact: )"t e 7-4,e Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector Present <br /> 2. SUNT IAItY OF TEST RESULTS <br /> Number of Tanks Tested: o� Number of Piping Runs Tested: , <br /> Number of Submersible Pum Sumps Tested: Number of UDC Boxes Tested: �} <br /> Number of Fill Sumps Tested: Number Of Overfill Boxes Tested: <br /> Component Pass I Fail Comments <br /> A ,v N c..e c-, <br /> 1 r � <br /> 3 <br /> 5V 44V <br /> y <br /> 57f 3 <br /> —77y <br /> i y <br /> Technician's Sign ure Date: <br /> f I � <br />