Laserfiche WebLink
01-20-'05 15;37 FROM- • T-514 P009/024 F-545 <br /> SWRCB, MAY 2002 too FINAL DRAFT <br /> Report Form -- <br /> SeCondary ontaminent Testing <br /> P fo written test procedures, and printouts from tests <br /> This form is intended for use 6y contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> e& The <br /> pages of this fo� o report <br /> results <br /> It toohe facilr all ity ty oaeats t petrator for submittal to the local regulatory agency. <br /> (ifapplicabie)o p <br /> 1. FACILITY INFORMATION <br /> Date ofTcsting: <br /> Facility Name: PG ( 57GG�crE� /� <br /> Facility Address: A1417119 <br /> Phone: 20 <br /> Facility Contact: ✓71k rn�/ C <br /> Date Local Agency Was Notified of Testing: <br /> (if g g) i/ie/% �e <br /> Name of Local Agency tnspcntor t resent duan testir CL,u- est <br /> 2. TESTING CONTRACTOR INFORMATION DRIVE <br /> Company Name: ACCI)-'PEST 1 <br /> Technician Conducting Test: ELDON I"IATIfIAWAI' <br /> Sao <br /> Credentials: 0 CSLB Licensed Contractor [�7 SWRCB Licensed Tank Tester <br /> License Number: 1002 <br /> License Type: <br /> anula(3111- fraininz Date Trai n x i es <br /> (�.nmt)nRC t s <br /> [Tann cln r / <br /> ,71IN <br /> MARY OF TEST RESULTS Not Repairs <br /> 3. SUM <br /> st YaII Not Repairs Component Paas Fall rested Mede <br /> Pa <br /> Component listed Made <br /> a/ '�! ❑ ❑ ❑ <br /> ��a/ry rte / ❑ L1 ❑ ❑ ❑ ❑ <br /> o• r �z ®' ❑ ❑ ❑ ❑ ❑ © ❑ <br /> QHN r 2� A Get,7j [1 ❑ ❑ r� ❑ ❑ ❑ <br /> El 0 <br /> ua 4a� ® ❑ ❑ o ,,� t« ❑ El 11vvG d,m�� 9 El <br /> o ❑ ❑ ❑ <br /> L] F1 11 ❑ # ❑ El <br /> vw. *F/ ❑ ❑ L1un3 v e <br /> ❑ ❑ © ❑ <br /> .4ZG ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> zs3 Bio 0 ❑ ❑ © ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER WAS PROCMEll <br /> CERTIFICATION OF TECHNICIAN <br /> RESPONSIBLE FOR CONDUCTIN THIS TESTING <br /> To the best of my knowledge, the facts stated in this docun,ent are accurate and in frill compliance with legal requirements. <br />