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- k % 1 0 0 S WRCB, January 2002 Page 1 cif Secondary Containment Testing Deport Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: v 4-,-4 Date of Testing: t Z (),g - Facility Address: I l l t L a 7L2 e tin^cern a,#Lrz Lo L, �15 2 p Facility Contact: 'jj,!:tr { Phone: Date Local Agency Was Notified of sting : 0 5 in � � Pass Name of Local Agency Inspector (ifpresent during testing: 2. TESTING CONTRACTOR INFORMATION DEI 2 3 22005 Company Name: P_ i Lc,,, 0 ENVIRONMENT HEALTH Technician Conducting Test ,, u u,, ; y , RMIT/SERWES Credentials: 0 CSLB License Contractor WRCB Licensed Tank Tester Pass License Type: License Number: 10 - tlS,0 Repairs Made Manufacturer Training^ Manufacturer Component(s) Date Training Expires Gt. 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made rry Gt. ❑ ❑ ❑ E) El El 5c`��, r ❑ ❑ ❑ ❑ ❑ ❑ ❑ Se Hsu �l'*eZ ❑ ❑ ❑ El El 11 ilk &I ❑ ❑ ❑ ❑ ❑ ❑ ?tn t, ❑ ❑ ❑ ❑ ❑ ❑ ❑ El El 11 1-1 7 r �,. * ❑ ❑ ❑ ❑ ❑ ❑ ❑ t4 b &J4 L LL ❑ ❑ ❑ ❑ ❑ ❑ ❑ UAL 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ LA V) C. 5 iv ❑ ❑ ❑ ❑ ❑ ❑ El L4,0 ❑ 1 ❑ ❑ 1 1 Uj ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: A l ( -T s -(- - (kA t d. SL,, n ,, ( t a_ d cwt ► � e e.o t,.e.r.,.c4 l ,i fL I kD (ft., CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,e facts stated in tlti •document are accurate and In full compliance with legal requirements Date:Technician's Si nature / !�