Laserfiche WebLink
°n ECE�]W E0 <br /> SWRCB,�January 2002 .S E P Tie M of <br /> Secondary Containment Testing Report FornINViII-XiNMENT HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sy",T&Rtg;C E S <br /> appropriate pages of this form to report results for all components tested The completed form, written rest procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner%operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 716eA X7 2 I Date of Testing: <br /> Facility Address: 1.32?, <br /> Facility Contact: Phone: ?— stz'3—'� <br /> Date Local Agency Was Notified of Testing: ei <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: � S G 50 <br /> Technician Conducting Test: .i'Lv,,,f L ,�t iL,, <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> ?Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fait Not Repairs Tested Made Component !Pass Fad Not Repairs <br /> Tested Made <br /> {LL p��R /LC 0 b K *1 11E L, 11 .� I ! 11J <br /> �t i� ciZ ❑ ❑ ❑ ❑ ❑ <br /> Q ❑ ❑ ❑ ❑ ❑ ❑ Q <br /> ❑ ❑ ❑ C ❑ ❑ ❑ ❑ <br /> 0 ( ElQ Q u C, <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ C ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECMNICWN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the fuets stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Siignature: 6C�� (-e ms Date: <br /> L1v � a <br />