Laserfiche WebLink
SWRCB, January 2002 Page of— <br />Secondary ContaI'� ent Testing Deport Form <br />This or•r77 is Mtendedfor 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, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory age77cy. <br />1. FACILITY INFORMATION <br />Facility Name: <br />Facility Address: <br />Facility Contact: <br />V <br />P 17,k L s <br />Date Local Agency Was Notified of Testing : <br />Name of Local Agency Inspector (if present during testing): <br />Phone: <br />Date of Testing: 848 o,s <br />C � 95ZV Z <br />r-rnvra r-+ntvmu A d"WIP UVFORMA TION: <br />Z. 1L�7jj1\lI l Vl\ll�ci.�iv-------- <br />Com any Name: FGo 2t� i►. <br />Technician Conducting Test: N -E. 1 <br />Credentials: ❑ CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type:. <br />Manufacturer <br />License.Number: OV -..'16-76 <br />Manufacturer Training <br />Component(s) Date Training Expires . <br />Component <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Component <br />momma <br />0000' <br />MO__ <br />momis <br />ma <br />oot�o <br />W-__wmmm <br />MW�� <br />0000 <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 hest of my knowledge, the facts stated in this document are accurate and ins ull compliance with legal requirements <br />Technician's Signature -G« -� - __ > Date: c�'� G 05 <br />