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SWRCB,January 2002 ) <br /> of <br /> Secondary Containment Testing Report Form o� <br /> Page <br /> This form is Intended for use by contractors performing per/odic testing of VST secondary containment systems, Use the <br /> appropriate pages of this form to report results for all components tested The compel -':d form, writtetest procedures, and <br /> n <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORRMATION <br /> Facility Name; <br /> Pacility Address;, j� � � � � <br /> Date of Testin ; - <br /> Facility Contact; <br /> 5k4v,-j2- V,\� <br /> Phone; <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector ffpre3ent during testi g); <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name; D G., <br /> Technician Conducting Test: ,�t �..� <br /> Credentials:'' C <br /> 0 GSLB Licensed C ntractor WRC$Licensed Tank Tester <br /> 11 <br /> License Type; License Number: <br /> O—/ oZ0 <br /> Manufacturer Training <br /> Manufacturer Com onent s <br /> Date Ir-aining Expires <br /> .3. SUMMARY OF TEST RESUL'T'S <br /> Component Pass Fail Not. Repairs <br /> b+L Tested Made Component Pass Fall Not Repairs <br /> (� ❑ Tested Made <br /> C 5� ❑ Q 0 Dc 3s ❑ ❑ ❑ <br /> t ❑ ❑ ° ❑ 0 <br /> �� ❑ ❑ <br /> D DVr <br /> p <br /> i h� N1 Dtc�n��µiM +✓ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion <br /> p n of tests: <br /> �'e5-�- t cL S u ��.d�-� � <br /> £ 1~3 Ccs-, " irx,,C f-? -F4 <br /> ------------ <br /> CERTIFICATION OF TECHNICIRESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In tit document are accurate and in full compliance wltlt legal requlretnen!s <br /> Technician's Signature: + f <br /> Z-1 Date: l( 8 <br />