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FEB.25.2003 9:43W SC;QiT CO • N0.607 P.9i11 <br /> Page <br /> SWRCB,Jamwry 2002 —of <br /> Secondary Containment Testing Report Form <br /> Kisjorm is intended for use by contractors performingperiodic testing of UST secondary Containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The complered form, written test procedures, and <br /> printouts from tests Of applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Data of Testing. l- '4- <br /> FacilityAddress: C,'b(,AA <br /> Facility COAMX. T'Pt y7 phone: aft}9 �G-2Z <br /> Date Local Agency Was Notified of Testing; <br /> Name of Local Agency Inspector(+f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Co4 Ci <br /> Technician Conducting Test;� <br /> Credentials; %CSLB Licensed Contractor jKSWRCB Licensed Tank Tester <br /> License Type. 4 B C. License Number: QZ^115 3 <br /> l4laggflictssrer Trafnine <br /> Manuf <br /> air Co nen S) TlAre <br /> CU -15-0. <br /> h- n <br /> 3. SUNDIARY OF TEST RESULTS <br /> Not Repairs Not Repein <br /> Component Pass Fail Tested Made Component Pala Fail Tested Made <br /> i4V a5 l i i 0 ❑ O Q ❑ Q <br /> ❑ ❑ ,� q 0 ❑ 0 <br /> V �k ` � ❑ ❑ Q ❑ q Q ❑ <br /> wc. _ ❑ a ❑ ❑ ❑ ❑ o <br /> � ❑ a El 12a ❑ ❑ ❑ <br /> ❑ ❑ ❑ D ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,descabe what was done with the water after completing of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CO.mMTCTING TMS TESTING <br /> To the best ofmy knowledge, the fads stated in this dacumeM are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />