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D1 <br /> ll <br /> 2007+ <br /> SWRCB,January 2002 Ei .:gONPAfNTHEALTH Page of <br /> Secondary <br /> � ,',TISERVI�ES <br /> Secondary Containment Te,:�tmg Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form 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 /> I. FACILITY INFORMATION <br /> Facility N e: La w &,s Date ofTesting: 12 12/O <br /> Facility Address; l`fBOQ rvv�ku f2�., — S 1y1e0A mea 5 ?A S3 3.6 <br /> Facility Contact: J;—;-SSt e— I Phone: Z3'1- 2- 7 / <br /> Date Local Agency Was Notified of Te 12 S D 6 <br /> Name of Local Agency Inspector('(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: �Z ) Cofie,,e e "T;�1 s <br /> Technician Conducting Test: �, a-444, i F. Q u 4.-a . J—K- <br /> Credentials: ❑CSLB License Contractor WRCB Licensed Tank Tester <br /> License Type:TGON /4-'F�SB1/' License Number: Q— / / ZZ-1 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Train;—Exves <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fait Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 14 hu Iec ❑ ❑ ❑ UP $tL-. ❑ ❑ ❑ <br /> Ai,wu(&tV—TZ4A4tc 3 0 ❑ ❑ ❑ p ❑ ❑ <br /> st-cev��- i I31 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secent "'7Z ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> 5GGo,,daJ Vi ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S K t,: 41 [ ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> r A2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> wr3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> C 1tz 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> U l'I ti 3 r ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> /d u /:-e J4 ,ccf ei ,rfd e;?ec C r t &w. /,'ustc.a <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowl2gel. jack stated in this 7e, <br /> t are accurate and in full compliance with legal requirements <br /> Technician's Signatur : . � .r,,..�.--- Date: Z / I <br /> r <br /> J\� <br />