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C 7 S WRCB, January 2402 Page ' of Secondary Containment Vesting Report Form — Spill Buckets This jorm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the_ facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: N 3 k c2 L ,rte S� +'Z�+ c C a Date of Testing. Facility Address: Q'oo CW, LL-;4�� ns . Z-0 A Facility Contact: I Phone: C ct L 3 C. ' C! 1 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): y N S C i 7',q lu ft(, 2. TESTING CONTRACTOR INFORMATION Company Name: Champion Precision Testing, Inc. Technician Conducting Test: �-14,v � N L ,bi 14.d &l �� ATE f l`' Credentials: X CSLB Licensed Contactor ❑ SWRCB Licensed Tank Tester License Type: D-40 License Number. 1304390 Manufacturer Trainins Manufacturer Component(s) Date Traming Expires 3. SIT-MMARY OF TEST i2FSITI,TS Component pass Fail i Tested 'Repairs Component '_dude pays Fait Not Tested Repairs Made 2� f- i LL 3 a ❑ ❑ ❑ ❑ ❑ ❑ ❑ 14 o ee. a tbK ❑ ❑ ❑ ❑ ❑ ❑ D ,e- = ie r- iso ,< ❑ ❑ ❑ ❑ ❑ ❑ ❑ t - v� ;, t3 ❑ ❑ ❑ ❑ ❑ ❑ rc� 1t1c1 <GG Lit, ❑ ❑ ❑ ❑ ❑ ❑ ❑ t <z r3a ❑ ❑ 0 ❑ ❑ ❑ ❑ .i>< -� r=ace l3a '� ❑ ❑ ❑ ❑ ❑ ❑ D If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESIPONSMLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the fads stated in this document are accurate and in full compliance with legal requirements Technician's Signature: ef-6 —' , `,lG� — Date: