Laserfiche WebLink
Page I of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performingperiodic testing of UST secondary containment systems Use the <br /> appropriate pages of this form to report results for all components tested The completed form,tiwitten testprocedures, and <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: Facility# /L'`SZ,' Date of Testing:. 1, _2 :3— <br /> Facility Address:.6-5 4,,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector (if present during testing): NA <br /> = I <br /> 2. TESTING CONTRACTOR INFORMATION _ <br /> Company Name: Wayne Perry inc. <br /> Technician Conducting Test: fi•rek <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Testet_ <br /> License Type: A B ASB C-10 HAZ D40 License Number:300345 <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Itaining Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> i <br /> Not Repairs Not Repairs ' <br /> Component51�' 100 <br /> Fail Tested blade Component Pass Fail Iested MadeEl 11 <br /> ❑ ❑ <br /> ❑ ❑ 0 ❑ --- — <br /> 010 <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 010 Li <br /> ❑ 0 ❑ - <br /> -- ❑ o ❑ ❑ <br /> ❑ ❑ ❑ C ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERIIFICATION OF IECHNICIAN 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 /> n <br /> Date: <br /> Iechnician's Signature: <br />