Laserfiche WebLink
03/23/2009 05:03 661634q930CONSTRUCT*KERN C❑NSTRUCTPAGE 04/07 <br /> S WRCB,January 2002 <br /> Page_L of <br /> Secondary Containment Testing Report Form <br /> Thi„form is intended for ttse by contractors perforrnitig periodic testing of UST,secondarycontainment systems, Use rhe <br /> app opriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from testa(f applicable),should he prpvided to the facility 0Wncr/operator fpr submittal to the local regulatory agency. <br /> 1. F ILITY INFORMATION <br /> [Name <br /> acility Name: ^C <br /> acility Address: v 1, <br /> v Date of Testing: d <br /> acility contact: Phone; <br /> ate Local Agency Was Notified of Testing <br /> of Local Agency Inspector(;f—1-1daring testing): <br /> Company Name: zm <br /> 2, TESTING CONTRACTOR INFORMATION <br /> T <br /> Technician Conducting Test: <br /> Credentials: CSip Licensed Contractor ❑SWRCB Licensed Tank Tester `J <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Com Hent s <br /> bate A venin Ex fres <br /> I SUMMARY OF TEST RESULTS <br /> Component Pass rail Not Repairs arr9 Not Re <br /> Tested Made Component Pass Fail P <br /> fJ ❑ ❑ Tested Mode <br /> CI ❑ IJ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ CI ❑ I_l ❑ ❑ ❑ <br /> ❑ ❑ lJ ❑ Ll Cl ❑ <br /> ❑ ❑ CI ❑ Cl ❑ ❑ ❑ <br /> ❑ l ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ f] ❑ C7 <br /> ❑ n ❑ ❑ ❑ ❑ ❑ ❑ <br /> u ❑ ❑ Li ❑ CI ❑ CI <br /> Tf hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TT:IIS TESTING <br /> To the best of my know I e,Uiefacts st ed in th(ls docuument are accurate and In full compliance with legal requirements <br /> Technician's Signature:_ �`C/� <br /> f �� <br /> Date: <br />