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Page _of— <br /> SWRCB,January 2002 it- <br /> S6 <br /> F�,t 1.111 <br /> Secondary Containment TesI'1 k_>I+t1I _ rm <br /> This form is intended jor use by contractors performing periodic testing of UST second9��`co g�ngi systems. Use the <br /> rop-iate pages ojthis form to report results for all components tested. Th43QQ1t/alor i 1vr►It ' test procedures, and <br /> �rtouts from tests (iij applicable), should be provided to the facility owner/operator jor submitral to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: yt C i Qi J oQ : Date of Testing: /O U 3 <br /> Facility Addres ":,;Ah Gig' C <br /> Facility ContactIPhone: el — 6s— <br /> Date Local Agency Was Notified of Testing : p 03 <br /> Name of Local Agency Inspector (f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Nam e: JP PETROLEUM SERVICE <br /> Technician Conducting Test: JOHN P Pi7UMALA <br /> Credentials: Ito€SLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 4n (2v�-A <br /> El11 11 ❑ 13 ❑ <br /> p,0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t ❑ El ❑ ❑ ❑ 11 ❑ <br /> ❑ ❑ El <br /> 11 El ❑ <br /> tl d- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> s tll Scc 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1111 ❑ I ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my Anowledge, the facts stated in this doc are accurate and in full compliance with legal requirements <br /> oechnician's Sign e: <br /> Date: �D �� <br />