Laserfiche WebLink
SWRCB, January 2002 page—of_ <br /> Secondary Containment Testing Report Form <br /> This Joan is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The complered form, written test procedures, and <br /> printouts from tests(lfapplicable), should be provided to the facility ownerioperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: { — <br /> Facility Address: %ifC <br /> Facility Contact: per: <br /> Date Local Agency Was Notified Testing <br /> Name of Local Agency Inspector(Ifpresent during siln : <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Narne: Champion Precision Testing,Inc. <br /> Technician Conducting Test: <br /> Credentials: X CSLB Licensed Contractor 01SWRCB Licensed Tank Tester <br /> License Type: D-40 License Number 804890 <br /> Manufacturer Training <br /> Manufactm Com aeattst Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Repairs <br /> Component Pau Fail Tested Made Component Pats Fail Not Tented Dude <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> I i' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C % ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C R1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ <br /> ❑ ❑ 1 .❑ 1 ❑ 10 ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tens: —t— <br /> F l art LSCS ts1oS Ju°t l�Yck :r,EJ t 6)f\6t —lCn'Aer- <br /> CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my lwordeage,the fads striated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:2}s / `Y� _ Date: w — <br />