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SWRCB, !anuary 2002 <br />Page ___ of <br />Secondary Containment Testing Report Form <br />This, rm is intended, for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested The completed form, u?71t,-n test procedures, and <br />printoutsfromtests (if applicable), should be provided to the facility ownerloperatorfor submitral to the local regulatory agency. <br />L,Ai-Yr.1rry MWIRMATFON <br />Facility Name-..,_ C, Date of Testing: L—Tp—!t� <br />Facility Address: <br />Facility Contact-. <br />Phone: 0 <br />ate Local Agency Was Notified of Testing:ame <br />Dof Local Agency Inspector (ifpresent Jvfi;;� testi <br />2. TESTING CONTRACTOR INFORMATION i <br />[Company Name: <br />Pass Fail <br />Technician Conducting Test: <br />RepairsComponent <br />Made <br />Credentials: WSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type., A <br />License Number: 'i e <br />Manufacturer <br />Component(s) Date Training Expires <br />El <br />11 <br />tiq v- 7 <br />Component <br />Pass Fail <br />Not <br />Tested <br />RepairsComponent <br />Made <br />Pan <br />Fail <br />Not <br />Tested <br />Repairs <br />—Made <br />El <br />11 <br />tiq v- 7 <br />❑ <br />0 <br />11 <br />❑ <br />El <br />D <br />EJ <br />11 <br />❑ <br />0 <br />U <br />F -I <br />El <br />❑ <br />5 U <br />-U <br />1-i <br />fJ <br />U <br />U <br />Li <br />El <br />11 <br />El <br />11 <br />El <br />EY' D <br />-1 <br />ED] <br />e <br />El <br />El <br />0 <br />11 <br />0 <br />FA - <br />0 <br />- --------- <br />LJ <br />❑ <br />El <br />El <br />El <br />El <br />D El <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />iTo the best of my knowledge,! f *trd in this docamemt are aceuFute and jnjuH compliance with legal requirements <br />Date. > <br />Technician's qignattire, <br />