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9ECEVEDD Al/ <br />SWRCB, January 2002 OCT 13 2009 <br />Page of — <br />Containment Testing ReN�IIRQ'U <br />SecondaryN„N,�ALTW <br />g P iRTES <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages oj'this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests ('applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I - F'Af~TT T'TV TV1WnDA,T♦'TTnW <br />Facility Name: - 1/_-u i„ ;., i J i i i <br />Date of Testing: <br />Facility Address: I (') /1 <br />Facility Contact: T) _� -� : .,, t:.�� ri Phone: (7. o f t <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency inspector (j'present during testing): <br />2- TF.CTTNr (YINTD A A- rnD iry /1D TR ♦ rrnxr <br />Company Name' - <br />— - --- ----- <br />Technician Conducting Test: „, _• 1 <br />�.., , . . <br />Credentials: ❑ CSLB Licensed Contractor <br />G.SWRCB Licensed Tank Tester <br />License Type: -1 ..0 [c- <br />License Number: <br />Manufacturer <br />Manufacturer Trainin¢ <br />Component(s) Date Training Expires <br />❑ <br />❑ <br />❑ <br />3. SUMMARY n]W TI .CT RFCTTT.T.0 <br />Component <br />p <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs4en,Repairs <br />Made <br />ComponMade <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />El <br />0 <br />❑ <br />❑ <br />❑IJ <br />%-JLj <br />PZ <br />❑ <br />IJh h <br />-' <br />J <br />❑ <br />❑ r- J <br />If hydrostatic testing was performed, describe what was done with thew ter after completion of tests: <br />'/ �'l `. t� 1. ,1 - : "�i ;.i:, l ,f- �7 '✓ , 'f" '{°fa � �^ '�'w! ll •��. .. :`l; .S.� 5,. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts slated in this (Ioe ttnenl are accurate and in full compliance with legal requirements <br />[echnician's Signature !�.7,...,,-. (',.r': -- - - e <br />Dat <br />�A <br />