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(� VV <br /> /Wu <br /> SWRCB,January 2002 IJL F' I� 11 I LJl <br /> Secondary Containment <br /> ' cJ08 Page of <br /> 1 <br /> Testing Report <br /> This form is Intended for use by contractors performing pertodte testing of LIST seconda c r�1°l l �� t I� HEALTH, <br /> appropriate pages of this form to report results for all components tested The completed for� ywrY/gip ed res a <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ad en <br /> 1. FACILITY INFORMATIONrY g `�' <br /> Facility Name: �j�/� <br /> Date of Testin 3 <br /> Facility Address;, 5 3 Co Oi,) <br /> Facility Contact;S ° ,o <br /> a►�. �z.✓ v Phone; � <br /> Date Local Agency Was Notified of Testing : a O <br /> Name of Local A enc Inspector i <br /> Agency p (fpresent during testin ; <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Natna; Il,111 119 OL Y\C-e <br /> Technician Conducting Test- ��u� y' ! <br /> Credentials; 0 CSLB Lir� f , <br /> Licensed ontractor <br /> License TypSWRCB Licensed Tank Tester <br /> e; V'>;�., <br /> License Number; O — 3- <br /> Manufacturer <br /> Manufacturer Training <br /> Com orient s <br /> Date Trainin Ex ices <br /> .3• $UMMARY OF TEST RESULTS <br /> Component Pass Fall Not. Repairs <br /> Tested Made Component Pass Fail Not Repairs <br /> ❑ 1 ❑ ❑ Tested Made <br /> Y # . ❑ 0 <br /> O <br /> h(A1ay­ f a0 K, Q ❑ ?;�`nr 0 0 ❑ <br /> n u otr.y . ..tt � ❑ ❑ ❑ �e ,✓� c5i�,ms�,� ,� <br /> nK t5 s-� Q ❑ 0 ❑ ❑ ❑ <br /> 0 <br /> 44 <br /> �y P <br /> yah r e ❑ ❑ ❑ <br /> CCorR�cn Elzt:� itBlta,F"ip <br /> ❑ ❑ - ❑ ❑ ❑ <br /> ❑ � � � <br /> CO- ah e ; Li E3 0 <br /> ° 1 k. ❑ ❑ <br /> V 0 ❑ bra. ( 0 ❑ ❑ <br /> If hydrostatic tof ting was Performed, describe what was done with the water after completion of tests: <br /> ------------ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In Idocument are accurate and lir full compliance with legal requiretne its <br /> 1 <br /> Technician's Signature: <br /> Date.. U <br />