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I-D-1������ D <br /> SWRCB, January 2002 OCT 3 U 2008 Page I of <br /> Secondary Containment Testing Repofftr-RVICES <br /> NT HEALTH <br /> This form is intended for use by contractors performing periodic gestin o �L1ST secunda o� s. , <br /> P g J ry e ntaurment systems. C se the <br /> appropriate pages of•this form to report results for all components tested The completedJbrm, written test procedures, and <br /> printouts from tests (if applicable), should be provided to the facility owner,'nperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:,L- Co-'q Date of Testing: <br /> Facility Address: 133t Sox tin �.-�u.tnn La�AsL L-z J-; Ca, Z 2-14 ! <br /> FacilityContact: DeSCallcki..- pl ;� GrCIly1,4lrl�,,s� Yy Phone: 333 <br /> Date Local Agency Was Notified of Testing: ',� -1 � <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: T) o, t c,,c..C q <br /> Technician Conducting Test: �V--�;11 UV,r <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type.-7-64,4`�T�+S y� License Number: <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> I SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repair Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> /ITN/G ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> G9ltil,�rii �oK/l_ 4 ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ <br /> �l;frac ;i _/�_- '- ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> rrc .,, 3 ,gyp iI'� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> c WO ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> elSc��.� „ _ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> f S i ,wr- _ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t � si ry 17 ❑ ❑ ❑ (7 ❑ ❑ <br /> If hydrost tic testinA was performed, describe (what was done with the water after completion of tests: <br /> T! (U �� SlAltEiti -'ter_ i, (f' (!h <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in-this document are accurate and in full compliance with legal requirements <br /> Fedirucian's Signature: '��__�,_ _- --- -- ----- -- Date: <br /> Sic <br />