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SWRCB,January 2002 <br /> Page 1 of <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. U.se the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: A 1ZCo *�L b (-CW-) Date of Testing: 9 <br /> Facility Address: 2-577 j S", J-A I Gey,- tJ IPA-55 D. T,ef► C t}. <br /> Facility Contact, N L Phone: Zv - 3 5 -77'7 7 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Z>i A1~ % tS 0 iz ►} <br /> Technician Conducting Test: U SSC LL 0 6 C-It 5 <br /> Credentials: ❑CSLB Licensed Contractor 2 S WRCB Licensed Tank Tester <br /> _ <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> r <br /> 3. SUMMARY OF TEST'RES.ULTS <br /> Component p Fe1� ,, Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> R El El 0 <br /> l-4S"1 w�i Fl c[ Su,�i ❑" Ci ❑ -A-3•- `is7 uu t=/rc Sur►,{' ® ❑ ❑ ❑ <br /> sl( -1t7r~tct_ �Pt� �u�/c`T ®`.. ❑ ❑ ❑ #3—a7 F/cC ect cx- ® ❑ ❑ ❑ <br /> *I- f57 Amo,,AcArt E ® ❑. C}.. O 4r3- $7 A.-.I.uaa2 5?4ce ® ❑ ❑ Ll <br /> 2-W7 WAAL t',Pia:r4SuP,.. A ❑ `gyp PIPIA; fir., & ❑ ❑ ❑ <br /> 287 �4Nu FaLt_ S ❑ ❑ 44- 91 u,4, it_( S«.r,F U ❑ ❑ ❑ <br /> *2-,9 SPiK utee7 . ® ; ❑ ❑ ❑ +14 _91 Fite- SP/ A"," ® ❑ ❑ ❑ <br /> Z-� t4�,✓Kca/� � 69,. ❑ ❑ ❑ - ( AN- 2 SPacc a 0 ❑ ❑ <br /> J7 SECON A P/PE. ❑ ❑ ❑ "Y- 21 sCCvN! PIFG 9 ❑ ❑ ❑ <br /> + z-97 5 wic.QAa A1-C A ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> 1- ITO ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 0 Ll EJ El LJ El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 /> Technician's Signature: Date: 11-2 - 02 <br />