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SWRCB,January 2002 Page / of tP Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form 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 suhmittal to the local regulatory agency, 1. FACILITY INFORMATION Facility Name: /-(a r-} I 6A 1 5 p„Q \ Date of Testing: v Q Facility Address: (3 pct e i i cr A v-Q , 5 o G Ef.4-av-i c4 , 152—o—? Facility Contact: vcA- Phone: (Z.o 9 L+ Y& 2 Date Local Agency Was Notified of Testing : f3 ZZ (� Name of Local Agency Inspector(rfpresent during testing): P�<::u v'ovL JF lue \2-4- 2. 2.t2. TESTING CONTRACTOR INFORMATION Company Name: i'D e a"P k a,\C-C Technician Conducting Test: �,,\n -F v� n Z-Y•, Credentials: 0 CSLB Licensed dontractor ,NWRCB.Licensed Tank Tester License Type.�j '� 1L T�5 -r-Y License Number: Q— !1.,L-4> Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made �e�or�cLu i >2.� 1 ❑ 0 El ❑ ❑ ❑ ❑ Sec.vehC' Z. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ 1 ❑ El EJ 0 0 1 d 0 5 H ❑ ❑ ❑ ❑ ❑ ❑ ❑ � s ,<,to ❑ ❑ ❑ ❑ ❑ ❑ o c ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests:: ltAl� S� �lC e cA,.c� ( � cveel+rt aav tSE' t. Co i et4tc_.C. CERTIFICATION OF TECMSICIANSPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowled e' e m facts stated in this cu nt are accurate and in full compliance with legal requireents Technician's Signature .�� A � ~� �f° -, Date: ti