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(hF <br /> SWRCB,January 2002 • Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested. The completedform, written testprocedures, and <br /> printouts from tests (ifapplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: btfilLpl, Date of Testing: V <br /> Facility Address: <br /> Facility Contact: A111kp ' o Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during les ng): tt , <br /> 2. TESTING CONTRACTOR INFORMATION <br /> EEL <br /> Company Name: AIMA S <br /> Technician Conducting Test: S „ .j J0AQ <br /> Credentials: 5:CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester HEgLT �NMENT <br /> License Type: Ad a i , License Number: U rMEN7 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ./ '5( ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ,.,..,❑ <br /> Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑Atf <br /> f . o� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> s ✓ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ Cl <br /> If hydrostatic testing was performed,de tribe what was done with the ater after comple/tion of tests: <br /> � 9s —ks F <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts sta to this d cument are accurate and in full compliance with legal requirements <br /> C, <br /> Technician's Signature: Date: <br />