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4 ' <br /> SWRCB, January 2002 <br /> Page A- of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors perjbrming periodic testing of UST secondary containment systems. C'se 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: f_p �1 f,,,t .,-, 0 J , . Date of Testing: <br /> Facility Address `�-Z Sn= -� t,, «;, V� ,�� }- S� Lo A-® , r �' <br /> 7? $ <br /> Facility Contact: P"1 v 2 ✓ u -Phone: <br /> (--2_,o <br /> Local Agency Was Notified of Testing: <br /> �-® 33 - <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Z v,. IAAA r - , <br /> Technician Conducting Test-- t t` <br /> Credentials: ❑CSI,B Licensed Contractor RCB Licensed Tank Tester <br /> License Type:--TcwA\c. .# <br /> � License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not [Rep-airs Not Re <br /> Tested Made Component Pass Fail peers <br /> A�/(/.��e. Tested Made <br /> a Io-uk 0' <uz 1 c- EI ❑ ❑ ❑ ❑ ❑ ❑ <br /> S e ek. #--1- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> _eAM El El El El El El E01 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> - ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ n ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after complettiion of tests: <br /> 7I 1 a ✓r tet ` ice,!t' t ' ( � ' r e r <br /> i <br /> T- <br /> __ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated Int : document are accurate and in full compliance with legal requirements <br /> (echnician's SignatBate: <br /> ure: I <br /> ——---- t <br /> V <br />