Laserfiche WebLink
SWRCB, January 2002 Page 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, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lo D /'YI o- ® Date of Testing: 3 - 2 "�S <br /> Facility Address: 9 7-75 5 t ® < <br /> Facility Contact: eg Phone: — 7l0 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION; <br /> Cornioany Name: 1A <br /> Technician Conducting Test: I <br /> Credentials: 0 CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. IN L License Number: &t r/ <br /> 7-6 <br /> Manufacturer Training <br /> Manufacturer Com o—s Date Training Expires . <br /> 3. SLTAMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> /1Sre ` LILL ❑ . ❑ ❑ ❑ <br /> D ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> D ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what w one with the water after completion of tests: <br /> CERTIFICATION OF T)E1EI1� CIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowleda t e ets stated i this document are accurate and in full compliance with legal requirements <br /> Technician's Signature Dater <br />