Laserfiche WebLink
S WRCB, January 2002 Page of <br />r 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: JO zA i&1 GC^41 Hba Date of Testing: Via. <br />Facility Address: Gkt? tnf ff 0 r ' �F'`j�'1 6"� <br />Facility Contact: Phone: . Z% <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (rf present during testing): �)'e v E c <br />2. TESTING'CONTRACTOR INFORMATION <br />Compan Name: _O R'� rI INS 11. <br />Technician Conducting Test: L fE 0 <br />Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type:. IN I License Number: 1 '.r ^ 11413 <br />Manufacturer Tra➢ninQ <br />Manufacturer <br />Components) Date <br />.7 M A r'% 7 nr+ rrT+CT DV Or TT rrQ <br />Component, <br />Component <br />000v <br />mom <br />o000 <br />0� <br />mom <br />ooncv <br />No <br />r.�ovvv <br />, <br />momma <br />Tf hvrlrnstitic 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 thiF document are ccu�ate and in full compliance with legal requirements <br />4�� <br />v^. Date: <br />Technician's Signature; <br />