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CP <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment <br /> appropriate pages of this form to report results for all components tested The completed form, writtT test procedures, and <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to A"9 #MV ,��gency. <br /> �Po""I`h'TAL <br /> 1. FACILITY INFORMATION HADE,O <br /> Facility Name: jay- �0 ti y,->f pit y i ..eA, Date of Testing: Z, -L 0 0 <br /> Facility Address: q 15 U l U d W c.1� c)v� �, Q <br /> Facility Contact: R, c-\,-\ W ; 1 �-,,S,�5 Phone:Czoi r- <br /> Date Local Agency Was Notified of Testing : l <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Y. �7) U-), - 7�., �Q-. e 54-z Vti. <br /> Technician Conducting Test:` .e,, &,.,u, :W.-e <br /> Credentials: ❑CSL73 License Contractor VSWRCB Licensed Tank Te ter <br /> License Type:r~ it✓ License Number:cl 0-1 1 Z„6 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass -Fail Not Repairs <br /> Tested Made Tested Made <br /> yZY1 I Ct <br /> T�&j 1L ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V1,om !d Y/ �Am kL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tlGorid 6� i i ,Q� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> +1n 'r, � ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ?'v^. ! ate€ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i i ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> oln�Y S , f ��. ev-f <br /> t , r <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document ar accurate and in full compliance with legal requirements <br /> 1 Z/Z6 � � � <br /> Technician's Signature.xi �--k-�- --�- �-'�- - '-�'�" r1. Date: f <br /> U <br />