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suv�U <br /> SW'RC13, January _2002 JAN 2009 Page_J_of <br /> Secondary Containment Testifi#ppMd�RR���II(��I(�FF lg " <br /> Thfs firm is intended 1br use hr contruclor's perlorming periodic testing oj'L'ST TeconY�t�'dr1l MIent si stems. L'.se the <br /> appropriate pages uJ'this Jis m to report results[or_ull c•omp�nents Tested The completed./brin,lvritten tester ocadaress-und - <br /> printoulr from tests (f upplic•uhle•I, should he provided to the Jucilitq•ouwer operator lbr.submittal to the hrcu/regulutum ugenct'. <br /> 1. FACILITY INFORMATION <br /> Facility Name:(J t r.., (l ,wt a Yc ( Date of Testing: 1 ! l (� <br /> Facility Address: I I L j ,j 1 < oa r <br /> Facility Contac ,/ z r+ 1;"y Phone: 3 - <br /> Date Local Agency Was Notified of Testing : t Z O. <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: .f n ;..., •, ;qui r : -"T-r' 1...' <br /> Technician Conducting Test:- .,`y o r , Y <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type. , ., ,. y License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date T—;-;-g Ex ires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail Tested Made <br /> u w,,t i rt/ L/.t, V2111 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 r4 f tr 'f 2 ❑ ❑ ❑ I� ❑ ❑ <br /> r _ <br /> n <br /> `r t t i rr^ a ere 1` i t ti (tL- I] ❑ ❑ _ __ <br /> rr r- , ,t 1:I L� ❑ G ❑ ❑ C <br /> ❑ ❑ - <br /> jq nnJ <br /> Ir <br /> 21 J <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> • t ( t Ley;..., , : -fAt ' r�r, "� <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best aj'my kncnvledge, rhe facts stented in this document tire aceurnle and in full compliance with legal requirements <br /> Technician's Si�nunrrc: ." ` , <br /> .. I yate: <br /> SJC— <br />