Laserfiche WebLink
SWRL'B,'January 2002 Pale of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems: Use the <br /> ., appropriate pages of this form to report results for all components tested The completed form, written test procedures, att�� <br /> _ printouts front tests(if'applicahlE), should be provided.tgiyhe facilh),oii ner.-'operator forstibmittal-to the local regulaton,agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: GI. P•t UP1 t /e 15 cltG,:::�/ !„S-4ri-r-4 Date of Testing: 2 /Z 11)3 <br /> Facility Address: Jf32 E.L Pf kld Pr, <br /> Facility Contact: u-PeA -5,-- Phone 2D1)933-7Qg4— <br /> Date Local Agency Was Notified of Testing -)-t S Q6 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Narne: R f 7,5 <br /> Technician Conducting Test: 7-54 44 '�tk�t e>`► r Gtkt� lG t jr <br /> Credentials: ❑CSLB LicensedContractor RCB Licensed Tank Tester <br /> License Type!' fLicense Number: 2--Yl7" <br /> Manufacturer Trainine <br /> Manufacturer Com onent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Com onent Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> 6l 1,14, si -7a--k �I e � ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> SeC r s -k 5e ❑ ❑ ❑ 0 1 ❑ ❑ 0 <br /> Sec daY zo-4`Z ,C ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ci wr , ❑ ❑ ❑ 0 0 ❑ ❑ <br /> C CESyr cl s , .�H*?f A 0 ❑ 1 0 ❑ 0 ❑ ❑ <br /> � .. IZ- ,� ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> 3 t / �' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t'✓ S € ' ❑ ❑ ❑ ❑ ❑ ❑ O <br /> �FIl2dSe ✓ S� � .. ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostats testing was performed, describe what was done with the water after completion of tests: <br /> �/S a.,cCl/-Y,� r 1 cv�.CEr e c l_ak^ lam. f � - a <br /> ri <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this'docuntent are accurate and in full compliance with legal requirements <br /> Technician's Signature: ..•-i_� t t..t. �'` t Date:—L2, V v <br />