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Y <br />s <br />F- <br />L -1 L <br />SWRCB, January 2002 <br />0 <br />Page ` of <br />Secondary Containment Testing Report Form <br />This form is intended for use by --o tractors performing periodic testing of UST secondmy containment systems. Use the <br />aPerWriate pages oJ'this farm to report results for aU amponents tested The completedform, written lest procedures and <br />prwto= from tests (if applicable), should he provided to the facility ownerlopemror f r submmai to dhe local regulatory agency. <br />1 _ FA1'n rrV rt VV1DMA'rWf%W <br />FacilitY Name: 012Lgtk.D&%. KT ------ Date of Testing: Z/5/'(Y3 <br />Facility Address: 2 7,,Ty 2�7 <br />Facility Contact: do/� i Phane: 2oY �' <br />Date Local Agency Was Notified of Testing: i r at /v -;j ' <br />Name ofLocal Agency inspector (if present during testing)- Sym eSc w; <br />2 TESTING CONTRACTOR INFORMATION <br />Company Name: �e C21 S <br />Technician Conducting Test w, m <br />Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: DtAo lieense Number: <br />M�nafietater Trs®ma <br />MambScOner C s Date Tntuang Exmres <br />3. SUMMARY OF TEST RESULTS <br />Cmnponeot <br />Pabbs I Fad <br />Tented <br />Made <br />CnmpeaeM <br />Pass <br />Fad <br />Tested <br />Made <br />NLcL /=rLL %3t. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />x4012 A. P x 3 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />ev <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />t t z 244-r <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑I <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑' <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />TO <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />G <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />C$RTIFICATION OF TECEMCiAN RESPONSIBLE FOR CONDUCTING TIRS TESTING <br />TO the best of my knowledge the fads stated in this document are accarate and in fuII eomp6ance with legal requirements <br />Technician's Signature: dZ'Gir' // 4 Date:-/ <br />