Laserfiche WebLink
0 <br />I� <br />U <br />SWRCB, January 2002 Page _ of _ <br />Secondary Containment Testing Report ]Form <br />This jorm is intended for use by contractors performing periodic testing of UST secondary containment systems. (Ise the <br />appropriate pages of this farm to report results jor all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerioperator jor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: OT RAA /35 --1 1 Date of Testing: <br />Facility Address: t -j Y Ly <br />FacilityContact: OdLpNpjPhone: <br />License Type: D-40 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ii/present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Champion Precision Testing, Inc. <br />Technician Conducting Test: &,( /P rn,f <br />Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: D-40 <br />I License Number: 804890 <br />Manufacturer TrrininQ <br />Manufacturer component(s) Date Training Expires <br />i <br />i <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CO"UCTING THIS TESTING <br />To the best ofmy knowledge, the fads stared in this document are accurate and in full compliance with legal requirements <br />Technician', Signature: -- Date: — ` i <br />NUMMM®I�G10©M <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CO"UCTING THIS TESTING <br />To the best ofmy knowledge, the fads stared in this document are accurate and in full compliance with legal requirements <br />Technician', Signature: -- Date: — ` i <br />