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10/19/2004 08:27 FAX 5629888165 S J WEAVER CONTRACTING 0 002 <br /> Page—L of <br /> Secondary Containment Testing Report Form <br /> This form is Intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all Components tested. The completed form, written test procedures, <br /> and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local <br /> regulatory agency. <br /> I.. FACILLITY INFORMATION <br /> Facility Name: ,r L 0 �q Date of Testing; 10, jq <br /> Facility Address: " �/ S <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: V p Cy <br /> Name of Local Agency Inspector Present: Z_& None present <br /> 2. TESTING CONTRACTOR IlVFORMATION <br /> Company Name: SJ Weaver Contracting Inc. <br /> Technician Conducting Test: �p,y�� f <br /> Credentials: X CBLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type and#: A,,hIaz,B Lic#717173 <br /> 'Draining by Manufacturer <br /> Manufacturer Conn onent(s) Date Training Expires <br /> INCON Sung s, UDC's 9/1/04 <br /> AO Smith Secondary Pi in 6/1/04 <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: Number of Piping Runs Tested: <br /> Number of Submersible P=p Sums Tested: Number of UDC Boxes Tested: <br /> Number of FiN Sumps Tested: Number of Overfill Boxes Tested: <br /> Component Pass Fail Comments <br /> c k ❑ <br /> G U <br /> r- <br /> G ❑ <br /> ❑ <br /> "All pressure testing must utilize an inert gas. <br /> Technician's Signature: Date: �S <br /> J <br /> R.C.U.S.T.COV December 2001 <br />