Laserfiche WebLink
�- SWRCB, January 2002 � <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 the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Date of Testing: <br /> Facility Address: toM EKONf <br /> Facility Contact: Phnue 01 qcS_ t <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if pr•es•ent during testing):5 sq"JO V64 N ti �f <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: I F(, ku <br /> Technician Conducting Test: K Gl V C M l M' ox re <br /> Credentials: CSLB celpsed Contractor tWRCB Licensed Tank Tester <br /> License Type: -3(p License Number: to <br /> Manufacturer Training <br /> Manufacturer Com onenY s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Passfail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> r NKk s <br /> P;PE 9VN <br /> 10415 01 Co AWA <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> `t'echnician's Signature: Date: <br />