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FROM :B.Z.SERVICESTRTION MAINTIWCE FAX NO. :916 371 2540 *ec. 09 2005 09:48AM P5 <br />r <br />SWRCB, Anuary=2 <br />Page of <br />Secondary Containment Testing Report Farm —~.y <br />This form is Intended for use by contractors performing periodic testing of UST S condary containment ,systems. Use the <br />apprnpriate pages of this•, form to report results for all components tested. The completedform, written test procedures, and <br />printouts fi'M tests (If applicable). should be provided to the facility Owner/operator for .subrriittal to the !opal regulatory agency. <br />1. FACILITY INTORMATION <br />Facility_ Name: 4 <br />Facility Address; <br />Facility Contact; <br />�Z± <br />Date Local Agency Was <br />Name of Local A¢on�v I <br />2. Tr, STING C, <br />CotnPHny >Vrune: -_ <br />Technician Conducting Test: !::S .,..t <br />Credentials: BCSLB Licensed Contractor <br />License Tyne: <br />N _Date of Testing��� a <br />Yhonc, 109_3(&-303 _ <br />iTRACTOR INFORMATION <br />Q SFdRCB Licensed Tank Tester <br />License Number: £/ 33l S _ <br />,Mnnufactureir Traf i�g <br />Com oncmt s _ DAIb Traitring <br />� vc> <br />3. SUMMARY OF TEST RESULTS <br />Component <br />t <br />Pass Fail NoRe ulrsTested Made Curttponent <br />Pass Irai <br />Not <br />Repo <br />' r,- ii& <br />❑ n o <br />Tested <br />Ma. <br />q <br />❑ <br />o <br />C)8E° <br />-&, r <br />❑ ❑ ❑ �. <br />❑ <br />0 <br />❑ <br />0 <br />r <br />6) <br />❑ p ❑ <br />f7 <br />❑ <br />❑ <br />LJ <br />❑ ❑ n <br />µ <br />Q <br />❑ <br />❑ <br />it o ❑ ❑ <br />—° <br />❑ <br />❑ <br />❑ <br />0 <br />El El F1❑ <br />a <br />❑ <br />❑ <br />n <br />❑ ❑ ❑ 0 <br />Li <br />❑ <br />o <br />11 <br />❑ ❑ 0 ❑ <br />� <br />CJ <br />❑ <br />U <br />El 0 Eli_l <br />❑ <br />~ <br />❑ <br />0 <br />EED- <br />0116 <br />El <br />❑ ❑ <br />❑ <br />❑ <br />n <br />❑ <br />If hydrostatic testing was performed, describe what was done with tho water alter cornplation of testp, <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To ific best of ;,vknyiv?edg the facts stated in tltts document are accurate and in jUll compliance witlr legal requiretrrcnts <br />Technaicisrn's Store <br />