Laserfiche WebLink
SWRCB, January 2002 Page 1 of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary cont2 )s2n3s. Aff I t i 1.8 <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submit5aAdd B � fgfncy. <br />1. FACILITY INFORMATION U P, A I T W r% r-.iEN T A 1 <br />Facility Name: G c,,i D L-cz L- avi- S, -r Q 1 c e- 5-%-�; o{ , Ay(3) Date of Testing` <br />Facility Address: Ot ov Sat,+ --I C.Ir c r -p V-., . La,. Lci,S, Ga . Ct 5;t 0 <br />Facility Contact: � i r' cc N � V+i ,,U =Lok„ Phone: O 3 3 �-� 1 Z, <br />Date Local Agency Was Notified of Testing: 11110 LDk6 <br />Name of Local Agency Inspector (rf present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: - f) C-0- <br />Technician <br />.0 Technician Conducting Test: -?j C, VVI I J.'\ L - ,VN, <br />Credentials: D CSLB Licensed Contractor KSWRCB Licensed Tank Tester <br />License Type: 1 r,,License Number: t -.— <br />Manufacturer Training <br />Manufacturer Com onent s Date Trainina Ex ices <br />3. SUMMARY OF TEST RESULTS <br />Com onent <br />p <br />Pass Fait <br />Tested <br />Not <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />h dew -titer 1t�. t� ]. Z z. <br />❑ <br />❑ <br />EJ <br />VD U -t5 CJ.. <br />11 <br />El <br />frb �i bt IGt+Y t.µ1 tL. 3 �`� <br />❑ <br />❑ <br />❑ <br />& tk; Z,f T <br />❑ <br />❑ <br />❑ <br />ceib c to t� i .l I <br />E <br />El <br />l�i 01-' �1 it 1 t7 <br />jr <br />El <br />❑ <br />�,.. c.uv"d 01. 7p oz- <br />-El <br />❑ <br />❑ <br />❑ <br />w et S <br />V <br />0 <br />0 <br />0 <br />�'.C.cvv" aA" <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />pw T� <br />0 <br />❑. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />l L <br />❑ <br />❑" <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />Lk. 03 <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />12 lnl�w,�.• <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />lh �� _.. L <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1_I �' 3 t ( <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this ant are accurate and in full compliance with legal requirements <br />--? <br />��TecDate: 1 a [51 <br />hnician's Signature:"M ,, «, <br />