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Secondary ainment Testing Report Page J— of 7 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures. and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: T, Tou u.n Courr Ge",vu' s Date of Testing: Facility Address: goo eS4 4C,5m i c( t> Facility Contact: O e R;;~✓b Phone: Date Local Agency Was Notified of esting: 1115 /,4:3 Name of Local Agency Inspector Present: 2. TESTING CONTRACTOR INFORMATinN Company -Na Technician Conducting Test: ^ C'('— ; cA Credentials: O CSLB Licensed Contractor WRCB Licensed Tank Tester License Type and #: 5 V/ (Z—c, Manufacturer L s C,,, 2_ 0 Training by Manufacturer Com onent s Date Training Expires Number of UDC Boxes Tested: Number of Fill SUMEs Tested:. Component Pass Fail Number of Overfill Boxes Tested: Comments kt tum Cc< ✓ Tc,-, iG— 0 ❑ r, L .e No -r--� Sa- rp t r red 9 GciN e 3. SUMMARY OF TEST RKSIIi,TS Number of Tanks Tested: Number of Piping Runs Tested: 2— Number Number of Submersible Pum Sum s Tested: Z Number of UDC Boxes Tested: Number of Fill SUMEs Tested:. Component Pass Fail Number of Overfill Boxes Tested: Comments kt tum Cc< ✓ Tc,-, iG— 0 ❑ r, L .e No -r--� Sa- rp t r red 9 GciN e ❑ tom C. UNvia-21 ❑ p4 jL e t c t vvl L. h eV, El— ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Technician's Signatur : �^ SWRCB Date: //31/03 December 2001