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SWRCB,January 2002 • • Page of g <br /> Secondary Containment Testing Report <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment � U pt tj <br /> appropriate pages of this form to report results for all components tested The completed form, written t Pr and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatoryagency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: a 5 e� I Date of Testing: <br /> Facility Address: 02-4 fe 09ve-, 6e . 15 336, <br /> Facility Contact:,.�"a�,., y` r I Phone: 2p-1 8 2,5-77Z2-- <br /> Date <br /> .5-77Z2— <br /> Date Local Agency Was Notified of Testing: Z 2g O <br /> Name of Local Agency Inspector(ifpresent during testing): M U ri ;4, pr, W 4.;cu R.•• E 5, <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name; 12 f Co w l t'.�wc< :•6 rvt <br /> Technician Conducting Test: � 4e W o v r, <br /> Credentials: 0 CSLB Licensed ontractor 4WRCB Licensed Tank Tester <br /> License TypeTt�,6t�Te5 E C Y License Number: '70 —l l 2 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> wvu44W I6twK-'Ilk1 ❑ ❑ ❑ -50J DUev ill box*Id--F ❑ ❑ ❑ <br /> tI'mdre v"1" Zt ❑ ❑ ❑ ;11 Ovav tlbax 44-2- -V ❑ ❑ ❑ <br /> Seu da ?Nag-Il'l ❑ ❑ ❑ t X'4 3 -r- 0 0 0 <br /> Stcohda i '*'Z. ❑ ❑ ❑ jjlrjj ~.Ctl *'"4-✓ ❑ ❑ ❑ <br /> e an t *k3 ❑ ❑ ❑ 1 ver ill x*5-F ❑ ❑ ❑ <br /> D I 6% ❑ ❑ 1 ❑ <br /> µy..i 'z. - ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> >t� w3 ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> � D6 7- tZ ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> uDc� y3t ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> u17 �5=t. X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Uq � � t� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testi was performed,describe what was done with the water after completion of tests: <br /> All z- ut i2 :? v " 1 ! <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated Inth' cument are accurate and In full compliance with legal requirements <br /> Technician's Signa �i�� Date: 3 tf� <br />