COMPLIANCE INFO 2003 - 2008 - Laserfiche WebLink

Home Browse Search

i7RCB, January 2002 DEC 0 F 200" Page of Secondary Containment Testing Report Fga �,j r HEAL H tats form is intended rot use by cdrirru tors performing petzodic testing of UST secondary contairuitersT`�S Use the avprovnate pages of this form to report results for alt components tested The completed form, written test procedures, and printours room tests (if applicable), should be provided to the facility ownerioperator for submirtai to the 16ca1 regulatory agency. 1. FACILITY LNFORMATTON Facility Name: % / , til Date of Testing: / .2 `a 3 Facility Address: l C q L O r C Facility Contact: Ka vG hone: C) Date Local Agency Was Notified of Testing Name of Local Agency Inspector (tf present curing testing): ? TESTING CONTRACTOR INFORMATION C OIIlpan Vtll Name: G ��i S1i1 l I TecumcianConducting gest Credentials: ' CSLB Licensed Contractor V❑ SWRCB Licensed Tank 'i ester License Type: 2` License Number: - M Mamtfacuuer M nufactarer Training i C onent(sl Date Training Expires i i 3. SUNLRY OF TEST RESULTS Not Repairs Component Pass Fad Not Tested Repairs Made Component Pass (Fa>3 ( Tested Made Z. tA 04W ❑ i ❑ ❑ S ❑ i i / ��.�Ga� ❑ i ❑ ❑ t - n f ❑ ❑ 2 w u�a� ❑� ❑ ❑ !/ Go �syAx ! ❑ U u v t% v6 •�• U i u .J /9 dI-l/41 ❑ i ❑ y/ /�Li -�+i I ❑ j ❑ 0 SGGOI✓ / G ❑ u ❑ / f �?% 14r S G� w -le, ❑ I ❑ ❑ -S- YAC i G L ❑ ❑ Ifhvdrostatic testing was peffortned, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTLNG THIS TESTING To the best of, my knowledge, the facts stm'ed in this docunaent are accurate and in frill compliance with legal requirements j Technician's Signature: Dale: -3---