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SWRCB, January 2002 <br />Page _1_ of _9_ <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 />1911 IVA 101011190 <br />1► 1 ►Y � 1 : 1�1' ! : l! c 1 <br />Company Name: TANK TEK ENVIRONMENTAL CORP. <br />Technician Conducting Test: RICHARD THOMAS <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A (CSLB Lic) License Number: 803705 (CSLB Lic.) -- 06-1672 (SWRCB Lic.) <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN #5254736 -UT DEC 28, 2012 <br />SCWRCB TANK TESTER LICENSE #06-1672 JUN 30, 2012 <br />FRANKLIN FUELING INCON SUMP TESTER #5012133701 FEB 8, 2013 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT 5 LABELED 55 GALLON DRUM ON SITE FOR LATER PICK UP <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. <br />�--L ut-� <br />Date: 4/3/2012 <br />ell 0 <br />87(1) FILL SUMP <br />87(2) TANK ANNULAR <br />KIM <br />87(2) PRODUCT SECONDARY <br />87(2) STP SUMP <br />la <br />■ 0087(2) <br />■ <br />0 <br />• <br />�� <br />DO�; <br />FILL SUMP <br />mmm <br />lam= <br />87(3) TANK ANNULAR <br />mom <br />—mmm <br />87(3) SYPHON PRODUCT <br />�SECONDARY <br />MM <br />�i 87(3) STP SUMP <br />mm�ll <br />lit <br />87(3) FILL SUMP <br />' <br />— ■ <br />■ <br />■ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT 5 LABELED 55 GALLON DRUM ON SITE FOR LATER PICK UP <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. <br />�--L ut-� <br />Date: 4/3/2012 <br />