COMPLIANCE INFO_2006-2012 - Laserfiche WebLink

Home Browse Search

RECOWED .SC January,SWRA', 2002 JR1 2010 Page �_ of Z Jams Secondary Containment TestiQ#0VW' * H 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 completedform, 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: cc vN Ju4Att±,n o n ; Qe r I v`ci A Date of Testing: Facility Address: So 0 11?,v,.rA, a wA ` 1' Facility Contact: <. -e ss e. E C_04.0 P one: r20 ) f $— 3 z,S Date Local Agency Was Notified of Testing: Z-ZZ — l v RT --w a. A - a Name of Local Agency Inspector(tfpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Cov, j) "'Tc 5 0 Technician Conducting Test;2� ,,, aW,,; Lt iAv,_ C-6-V& S r Credentials: ❑CSLB Licensed ontractor WRCB Licensed Tank Tester License Type: License Number: v i►Z-d -3;,ccr 5 z`2 6 b o-L—i^- T` Manufacturer TrAining Manufacturer Component(s) Date Trainin Ex ices 3. SUMMARY MMARY OF TEST 1 RESUL 1 S Not Repairs Component Pass Fail Not Repairs Component Pass Fail Tested Made Tested Made C 60 cLet V f -t�t-3� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ ❑ ❑ El 1) 11 1111 11 El 11 11❑ ❑ o El 11 ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done.with the waiter after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,thefacts stated In flits do nt are accurate and In full compliance with legal requirements Technician's Signature _�- Date: `'` "` _ _