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SNVRCB, January 2002 • • page g I --of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of i 1ST secondary containment systems. Use the appropriate pages of this, form to report results for all components tested Ae completed, form, written test procedures, and printoutsf•om tests (i f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name:��,.. Date of Testing: Facility Address: 4 ys� � e r�nn S�ort,;r o�—_ Facility Contact: _ Phone: Date Local Agency Was Notified of Testing_ Name of Local Agency Inspector (ifpresent during testing' )' 2. TESTING CONTRACTOR INFORMATION Company Name: Champion Precision Testing, Inc. _ Technician Conducting Test:M Credentials: X CSLB Licensed Contractor 11 SWRCB Licensed Tank Tester License Type: D-40 I License Number: 804890 Manufacturer Training Manufacturer — Com nent(s) Date Trafnfn E ties Repairs 3. SUMMARY OF TEST RESUI TS Component pass ;Fail Not Tested Repairs Made Component Pass Fall Not Repairs Tested Made i� ;tea 5 1 11F1 11 � t ❑ ❑ ❑ _��.��n,�._.��.m��-a _ - ❑ �� [� ❑ ❑ ❑ «�df 1 ❑ n ❑�C .3�.—nom_ s �� L)❑ L)Svc � 1_ FJ❑ ❑ - ❑ ❑ ❑ F41 ❑ ❑ ❑ ❑ f? r zt 7 LJ ❑ ❑ ❑ Cl ❑ 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 hest of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:_ f '� - Date: T-0 h r% s