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 LIST 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(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: . p ,} r Date of Testing: �} o d <br /> Facility Address: o 0 3 F. P,0 <— aIS <br /> Facility Contact: c� Phone <br /> Date Local Agency Was Notified of Testing: /i <br /> Name of Local Agency Inspector(if present during test ng): <br /> 2. TESTING CONTRACTOR INFORMATION: * <br /> Company Name: a- _ T t <br /> Technician Conducting Test: <br /> Credentials: 0 CSLB Licensed Contractor XSWRCB Licensed Tank Tester <br /> License Type:. License Number: 7 <br /> Manufacturer Training <br /> Manufacturer Component("s Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ El <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 /> Date: <br /> Technicians Signature: <br />