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(w'F <br /> SW,RCB,January 2002 Pie L of <br /> Secondary Containment Testing Report Form' j L1_N <br /> This form is intended for use by contractors performing periodic testing of UST secondary contai>ln ht S stenNse the <br /> appropriate pages of this form to report results for all components tested. The completed for �I ritten test proce`d�ures, and <br /> printouts frp. a tests(if applicable), should be provided to the facility owner/operator for subAN Air, kofgwy agency. <br /> IN <br /> 1. FACILITY FORMATION PERiMiT/St:R�1UES <br /> Facility Name: 1 L rf k., e Date of Testing: ZZ � <br /> Facility Address: (�S spy�-�}n ` Yc� 5 VV�2C,tn <br /> CotW12 C.; 16 2,,,3 1 <br /> Facility Contact: G lt. e Z Phone: ZoQ <br /> Date Local Agency Wa Notified of Testing: Z0[0-6 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 2Z i «.r -I _T�&5-t-vv <br /> Technician Conducting Test`_p"^,,aw i"I 1p-_ 0?C_ A^ V- <br /> Credentials: ❑CSLB Licensed --tractor CB Licensed Tank Tester <br /> License Type.�,,,`t_T,c$-�-c.� License Number: ()--1(2,_0 <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> I�►�wla✓ i�- � ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sera•��a c � 11 El <br /> 0 El El F] <br /> ecVt lt2- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e ce,,n d i ¢S2 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t)W6k ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1n ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1If- Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> tr -3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �--W- '5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> i S-I uig rteo ✓act 4w. ycatj V W 41 D <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated 1 is document are accurate and in full compliance with legal requirements <br /> Technician's Signature -- Date: 8 12 3 10a <br />