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,SWRCB, January 2002 Page of Secondary Containment Testing Deport Form f This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appr•opr•iate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: — �Gt' I �a v `Z Date of Testing: t` ' o= -F Facility Address: �0 Facility Contact: /V /-f r Phone: Date Local Agency Was Notified of Testing Name of Local Agency Inspector (tf pr eserzt during testing): T� C"T7TTl-t rnxTrp A rlrnR YNFORMATION -- r K A r.tr 11TT TL'C`T DVQTTi TC Component Pass Fail Not Tested Repairs. Made .- Component Pass r:ui Not Tested Repairs Made vt a r rY1t3 � ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ /t s- k laze❑ �' ❑ ❑ ❑ ❑ ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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 knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: