Laserfiche WebLink
K <br /> Page _of^_ <br /> N1iCB, January 2002 <br /> Secondary Containment Testing Report Form <br /> form is imendedJin•use by contractors per rt resultsforming perriiodic testing of UST seco dary containmentm, written systems. Use the <br /> and <br /> ropriate pages oJ'thisfbrrn to licable),e�mould be provideor ld toalhe faciiiry onents owner/operator for subed ne mittal ttal to the local regulatory agency. <br /> oriniouts from tests(if up% <br /> 1. FACILITY INFORMATION <br /> Date of Testing. 4 O <br /> Facility Name: <br /> Facility Address: Phone: �o2d�/ ' �s�.?bl <br /> Facility Contact: S <br /> Date Local Agency Was Notified of Testing : p <br /> Name of Local Agency lnspextor (ifpresem during testinp�: <br /> w <br /> 2. TESTING CONTRACTOR INFORMATION OC <br /> Company Name: JP PETROLEUM SERVICE v " <br /> Technician Conducting Test: <br /> Tank Tester <br /> Credentials: m:CSLB Licensed Contractor ❑SWRCB Licensed S <br /> License Type v <br /> Manufacture <br /> Com onent(st(s) ine Date Train Expires <br /> Manufacturer <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Pass Made- — <br /> ainor to D ❑ ❑ ❑ ❑ ❑ {J <br /> i JR R7.9 ❑ �J ❑ ❑ ❑ ❑ ❑ <br /> I ' fT C1 ❑ ❑ <br /> ; II ❑ ❑ ❑ ❑ oCl a ❑ ❑ <br /> — ❑ ❑ <br /> El D 13 11 Ll <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D o 77. ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TEAS TESTING <br /> go the best of my Anowiedge, the facts staled in this doc mens are accurate and in fail compliance with legal requirements <br /> Date:li�� <br /> Technician's Sign' <br />