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swRCB, January 2002 01AU3S�1JVV83d Page i of � • 3N 1N3lNN08U1N3 Secondary Containment Testing RepoiSpfWj%3q AG This form is intendedfor use by contractors performing periodic testing of UST secon ontainment systems. Use the appropriate pages of this form to report results for all components tested. The compl t {� eedures, and ff ould be provided to tLSfacility owner/operas tArokto datery agency, 1. FACILITY INFORMATTON Facility Name: 'I (L�-{ , �, e 1 { Date of Testing: - ?_ Z. !) Facility Address: 'iz.o7�}.Ir �, 3C..ti,", S Facility Contact: rrt t (CP Phone: Date Local Agency Was Notified of -testing: 1 1) Name of Local Agency Inspector (i(present during testing): 2. TESTiNr. f:ONTRAf TnR i7 FnlllMATYnX Company Name: TZ I)CM.: t , eevr v T`--' i Technician Conducting Test:' -b e �,t, ; -, r , })„ . , r Credentials: ❑ CSLB Licensed Contractor JRSWRCB Licensed Tank Tester License Type: 1 -; ,,, ,. -T-P -4. e y- License Number: 1 a Manufacturer Manufacturer Tra inine Component(s) Date Training Expires Repairs Made t a ,4 3. SUMMARY OF TEST RF.CITI.TS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made t a ,4 ❑ ❑ ❑ El 11 ❑ .3. ❑ ❑ ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ C El El El El 13 EJ El l�„ �P fr t cin f. �t �7 �❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ^'lr, r:I ., it I Ilt� .❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ q ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ vtA <,r<u.a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ r,, r ..,❑` ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this docr ument are accurate and in full compliance with legal requirements Technicikm's Signature:_ Date: C-t-