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t <br /> SWRCB,January 2002It <br /> Secondary Containment Testing Report ForiWAR 0 4 2003 <br /> -'';s forna is intended fin-use by contractors pefforming periodic testing or UST secondary containmerqp sf� �.sl!i tie <br /> ro mate a es o this orm to report results or all components tested. Tlae com leted orm, written to <br /> A• P S 1� 1 P ' P P ,• <br /> printouts from tests (1f upplicable), should be provided to the facility owner/operator for submittal to the local re ' i ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name p C, t / Date of Testing: �3 T <br /> Facility Address: �l t , r.levt —46-4—t 04 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : 5 <br /> Name of Local Agency Inspector(iI'pr•esent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP PETROLEUM SERVICE <br /> Technician Conducting Test: �� <br /> Credentials: x:CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type License Number:61-1211-1— <br /> �. <br /> Manufacturer Training <br /> Manufacturer Cotnponent(s) Bate Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Componena Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> a c>✓t ❑ ❑ 0 ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ Q ❑ ❑ L <br /> ❑ ❑ u -70 11 _ ❑ U <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ L1 El d 11 ❑ �❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 D ❑ U <br /> ❑ Ll 11 110 ❑ ❑ o_. <br /> D ❑ ❑ _❑ <br /> ❑ ❑ ❑ ❑ G ❑ D ❑ <br /> 110 ❑ ❑ 0 ❑ ❑ J <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CER'T'IFICATION OF ITCHMICIAN R.ESP©NSIBLE FOR CONDUCTING T]F"S TEMING <br /> To the best of my knowledge, the facts stated in this do c ent are accurate and in full compliance with legal requirements <br /> -I/ <br /> Technician's Signatu '% _� Date: . $ <br />