Laserfiche WebLink
''�'� •• - Enclosure #5 <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 of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(rf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACLLH Y INFORMATION <br /> Facility Name: Date of Testin E- <br /> Facility Address: <br /> Facility Contact: BROA-cc Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector{if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contmctor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <br /> M4eatactu�es�'raislag <br /> Mtaw�clurer g) Doi*IT@ft Expk= <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Rgwir, Component Paas Fail Not Repairs <br /> Pass Fail <br /> Component Tested Made Tested Made <br /> C� 19 ❑ 0 ❑ (h �* G ❑ ❑ ❑ <br /> x El ❑ ❑ ❑ ❑ ❑ <br /> ❑ 11 11 l 6�10 J1111111O1 b� 0 El ❑ ❑ ❑ <br /> LA,np <br /> Line 11 ❑ ❑ 11 11 <br /> $i ❑ ❑ ❑ D ❑ ❑ ❑ <br /> L; �+ as ❑ D ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> Took N46 PC ❑ ❑ ❑ ❑ 0 11 ❑ <br /> �► a ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESP"IBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated to this document are accurate and Infill compllance with legal requirements <br /> Technician's Signature: Date: <br />