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c< SWRCB,January 2002 j Page_of Secondary Containment Testing Report Form—FINAL DRAFT This form is Intended for use by wntr actom perfww ng periodic testing of UST secondmy containment systems. Use the approprtatepages of this form to report results for all components tested. The completed form,written testprocedures,and printouts from tests Cf applicable),should be provided to the facility owner/gator for submittal to the local regulatory agency I. FACILITY INFORMATION Facia Name: Atzeo b 100 I Date of Testing: '2-bZ FacilityAddress: 7-S .5. PA— t.3 PASS 45 ---FR-Acw CA. Facility Contact: N I$-t- I Phone: Z0,,i 3 S 77 77 Date Local Agency Was Notified of Testing; Nerve of Local Agency Inspector rjfpresent during testing): l I TESTING CONTRACTOR INFORMATION ' CoW=y Name: I>i A4 g 1. Ij 6 jt—( \ _ Tocimician Conducting Test L.1 p 6 t'`it g - Cmdentials: O CSLB Licensed Contractor 2 SWRCB��icen3_ed Tank Tester License Type: Lrcens�Number. jF 2 9 2 Manufacturer Trai�lnn --- Manufacturer B ` Date Tmining Expires 3. SUNUM"Y OF RE$,ULTS airs Component Pass Fail :I ed M de .\ <..\ Component Pass Fail Not Made #l• $7 u(.( Pr 1a0,t 5,,«tA J IN 'rd' � ❑ �7 a Nt1 P( ® ❑ 1 ❑ ❑ A1-9714NLFru. -iio 'f:7-' Sal av1=1c,c Sung e IN ❑ ❑ ❑ 'R7 F, 5f cc &c4e-r ®''I ❑ -[i o 0 3 ts7 Fico 1 8,,c-r,-r N ❑ ❑ ❑ i• S7 14ut.,,44,a,t E ® �,. f �'EJ 03-$7 /4►+NutAje Srkc ® ❑ ❑ ❑ 7-W744NLt'r+�P��u�.P�-. ❑ '•11 C] 414-`!l wu PIP1Ar fiI 0 ❑ ❑ 42-S7 !AN t{/+-[. `a ❑ ❑ ❑ 44—91 y F1LC Su MI P to ❑ ❑ ❑ tk2-� aN S�iz� LTA ❑ ❑ ❑ Q4 -91 Fttr: 5P1 B ® ❑ ❑ ❑ *2-V Ai,,"(,A2 �;-rsvtt•\ )W 1 ❑ ❑ ❑ -q( A.V#-, a S Acc 0 ❑ ❑ ❑ 4'2-k7 SEe00 A PI f", IE ❑ 0 ❑ 14- 9151-- 8 P 51 ❑ ❑ ❑ if ❑ 0 0 ❑ ❑ ❑102-al 87 a Cl ❑ 0 ❑ ❑ ❑ ❑ 142-J7 SAN*a P1 1-C ❑ 0 Cl__ ❑ ❑ ❑ ❑ if hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my know Ledge,the facts stated iii this document are accurate and in full compliance with legal requiremen& Technician's Signature: Date: