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Secondary Con illlent Testing Report ForAs Page I- of, 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. I. FACILITY INFORMATION Facility Name: %,, o yt Date of Testing: la p ?-- Facility Address: 23 , Facility Contact: G 1L Pone: --t G" 1 (11WO Date Local Agency Was Notified of Testing: I Z et o 7, - Name Name of Local Agency Inspector Present: 2. TESTING CONTRACTOR INFORMATION Company Name: R� 06 C,4v-. 1 ► et,�,.� -1j-s s e v, Technician Conducting Test. ev. Ih �. Credentials: O CSLB License Contractor ,tSWRCB Licensed Tank "fester License Type and #: 5 vi d, e.. C3 Manufacturer (_s C. Training by Manufacturer Component(s) Date Tra,ining Expires Number of UDC Boxes Tested: Number of Fill SumEs Tested: Component Pass Fail Number of Overfill Boxes Tested: Comments l&V—I`wwk.- ❑ 0 $.S Pq oo, A'Z- 0 3. SUMMARY OF TEST RF,SIII .T, Number of Tanks Tested: Number of Pipirip, Runs Tested: Number of Submersible Pump Sum s Tested: Number of UDC Boxes Tested: Number of Fill SumEs Tested: Component Pass Fail Number of Overfill Boxes Tested: Comments l&V—I`wwk.- ❑ 0 $.S Pq oo, A'Z- 0 D C �vrs we-.�w4-S Q DD 4 3 4wi ❑ ❑ See_ S a Af ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Technician's Signature: SWRCB Date: Z �-- December 2001