Laserfiche WebLink
FROM :TLM PETRO LABOR FORCE FAX NO. :5629238138 g. 18 2004 04:57PM P2/6 <br /> FROM :"Ln PETRO LABOR FORCE FA;, NO. :562923(313e Aug. 02 2004 05:00PM P1/3 <br /> SUc'R(`g,January 200:± r� of 3 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use hyo contractors per/orming periodic testing of UST vecondary cnnlalnment ry hams. 1lso.the <br /> approp-iote pages orchis form to report results for all components lesied rhe completed form.written test prrr 00''rev,cml <br /> prink�tfts fr torn tests(tfapplicable),should he provided tc the facility owner,'operatot•for,rf hmltlal to the local requlutory tog ner. <br /> I. FACILITY INROU MATION <br /> Facility Name-, Rao Wflw- Dote ol'Testing: <br /> Facility Address; tad �6, wluow <br /> Facility Contact: Phone: zo <br /> Dae Laval Agency Was Notified <br /> i Name of Local Ajency Inspector(tfpresem during testing): , <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Com anv Namc; T t-A <br /> Technician Conducting'fest: �.9gie&fr,& ��y�,tp atx�k <br /> Credea,tials; `CSLB Licensed Contracted C1 SWRCB Licensed Tank Tester <br /> License Ty Al C40License Number. <br /> if 5-5- <br /> Manufseterer Traldng <br /> Manufacturer— Component(!) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> CumNot Repairs pnnPaw ilparont Pada Frill Comoat PFa <br /> Tested _Made ...-•-------__- ...------.---,_I••_ Not Rapairo <br /> Tested Made <br /> t I Iii j4 T- _.- _._._ _ w - <br /> Cl l7 C 1=i Ct ❑—. i <br /> —------ - - -- - ---- __�_. - -- r— <br /> ❑ A 0 ❑' ❑ rJ + Q F1 <br /> C] ❑ ❑ 0 ❑ LJ 0 I-i <br /> Fa D n a O n a a <br /> r_: n __ ❑ r n <br /> 11 El <br /> If hydrostatic testing was perfortned,describe what was done with-the water after completion of tests: <br /> CERTIFICATION OF TLC H NIC:IAN Ithbr INSIBLLt FOR CONDUCTING THIS 1'"+*1 IN'G <br /> To the best of my knrawledge,the fads stated In thU domment are accurate and infull compliance with legal requireneeff" <br /> Technician'ggignatura ...._...---_ r / Date. i d ^�.--...._.....-...___. <br />