Laserfiche WebLink
" SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended.for use by cam•aciors performing periodic testing of UST secondart,containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts IrOln tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: G v P d o TDate of Testing: — ,,' 0 31 <br /> Facility Address: 7 ZZ o Cif <br /> Facility Contact: j�ti SC Phone:�p9-6 9�Date Local Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(if present during testing): p,U <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 7 1,4 Iv l/ 5 S <br /> Technician Conducting Test: 0j.4j <br /> Credentials: )�CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ASS ff Z G—/Q License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> G vv1 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ N ❑ ❑ ❑ ❑ ❑ ❑ <br /> tJ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ Q� ❑ ❑ ❑ ❑ ❑ ❑ <br /> Gt ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> v� d ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ El ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: of rill/l I-Iel"62—I Date: <br />