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Jan 03 07 04:19p Rfforda Test (209) 744-0116 p.7 <br />SWIZCB, January 2002 Page / of •2, <br />Secondary Containment Testing Report Forms <br />This form is inteltded fi r use by contractors perfa,•mille pe,•iodic testing of UST seconda,y containment systems. Use the <br />approp,•iate pages of this farm to report results for all components tested The completedform, w, itten [est procedures, and <br />printoutsfrom tests (,f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY MORMATIOl`r <br />hate of Testing: 1 <br />Facility NamO: 0 / )1,� <br />Facility Address: 9 CSU V'CJJ,� r <br />r r- t <br />Facility Contact: k. (14 r- '� >a 1 �� Phone: <br />bate Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />.2. TESTINO'CONTRACTOR ICNFORMATION <br />Com an Name: r <br />Technician Conducting Test: <br />Credentials: 0 CSLB 'Licensed Contractor SWRCB Liecnsed Tank Tester <br />License Type Liecnse Number: <br />Manufacturer Trainin <br />Manufacturer Com anent s <br />If hydrostatic testing was performed, describe what was done with the water atter corupienvn ul =A,). <br />CERTIFJCATION OF TECHNICIAN TZL, SPONSIBLE FOR CONDUCTING THIS TESTING <br />To t/te best of my knowledge, 1! ffias stated in this document are aecurrate and in full compliance with legal requirements <br />Date: 1 O -A l e 5 — <br />Technician's Sipatur <br />