Laserfiche WebLink
SWRCB, January 2002 <br />Page i of .- <br />Secondary Containment Testintn <br />g Report Form <br />This form is intended for use by coi7tractors 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 />T 1 �TT TT'%7 rAtTllD AIT A TT"W <br />Facility Name: Kf S 6"'°y L 1 rZ.aCe 1, f Date of Testing: ra <br />Facility Address:%6/ �, �.�,rry�. i`� z. Ge % S t C. P«U,J . c g 0 tG <br />Facility Contact: Phone: 1/6 7 - 0 30: <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (f present during testing: r � N � t�' I �+�F' �" <br />m�L-rrrnTi-'r-nrrru A r'TnR WFORMATION <br />Company Name: <br />Technician Conducting Test: 1 y <br />Credentials: 0 CSLB Licensed Contractor <br />License Type: . <br />Manufacturer <br />WRCB Licensed Tank Tester <br />License.Number: '77 = /I V <br />Manufacturer Training <br />Date Trai <br />-7 !lT TTCIT F) C'TTT rr10 <br />..®M�� <br />Component <br />1 11 <br />®®® <br />r�e�� <br />000w <br />mom0000j <br />WW= <br />raoor� <br />If hydrostatic testing was performed, describe what was done with the water atter compiII VI <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledb e, the facts stated in tlzis document are accurate and in full compliance with legal requirements <br />Technician's Signature: ,i `s' �'�'` ^�� Date: Co 184 <br />