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RREC DDD SWRCB, January 2002 Page of Secondary Containment Testing Kep�A fil�m This form is intended for use by contractors performing periodic testing of(1� � *_�'g)Ubten �t l A systems. Use the appropriate pages of this form to report results for all compone; its tested The RN� test procedures, and printouts from tests (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. 1. FACILI i Y INFGWv1ATIGiV Facility Name: p 63W ec 2rPT751fJ Date of Testing: r,oL Facility Address: �9'p0 S 6�2dkt L E L.o ► cf+ , Facility Contact: t,//, Phone Z ) 3;9_58c/ Date Local Agency Was Notified of Testing i Name of T ocal Agency Inspector (if present during testing): i 2. TESTING CONTRACTOR INFORMATION Company Name: � c Technician Conducting Test: 3��p�—r—i' _ Credentials: CSLB Licensed Contractor A ❑ SWRCB Licensed Tank Tester License Type: T \r1 an\L F-A� License Number: Manufacturer TraininE Manufacturer Components Date Training Expires 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: Component �® ■®OE 0 FOR, I 01.73M - h- a®� 7rdidMEN a©oma ■ ■ ■ ■ IN o®� �� ■ ■ -- , a m®0 moo=�1 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: