Laserfiche WebLink
S WRCB,January 2002t Page / of <br /> Secondary Contatment Testing Report Form' <br /> This form is intended for use by contractors performing periodic testing of UST secondmy containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:FcA S q 2�A # b I Date of Testing: �Oh <br /> Facility Address. 1 b k��� '� S h Lr. 52- 1 <br /> Facility Contact: p` Phone 2 p� ) t <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): 5p*.) 1 U <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: INIF1- 1^?5 <br /> Technician Conducting Test: LJAQ i Yv1Y"1() <br /> Credentials: ❑CSLB Licensed Contractor ASWRCB Licensed Tank Tester <br /> License Type:. License plumber: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SIJivllvYr'sRY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> X ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> v�1 Il f�Ucti / ❑ 1 ❑ 1 ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ <br /> esel sill �,'.�c!�Pa ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Si i u"/ i3% / <br /> �ature: Date: <br /> �i <br />