Laserfiche WebLink
SWRCB, Sammy 2002 Page 1 of Z <br /> Secondary Conta"Mment Testing Report Form <br /> Thfs form is intenrded,fig use by contractors pe ing periodc testing of UST semndwy con syst ma Use the <br /> apprWuW pagesof this form to report remits for aU caoWwaom tested 77w completed farm, wnzfen M&pwcsdww,and <br /> printouts from tests(tf 4PP&abde}.-*OWd be PVW to dxfi=ihy owrnr/aperaWr for submental to the local re <br /> 1. FACULM INMBMAnON <br /> Focality Name: 141A of Date of T /2-5 o3 <br /> Facia ty Address: /cL->tE,4,t-rz,— <br /> Facr7ity COntaet: <br /> Bate Local Was Noffied ofT R !9l®"3 <br /> Name of Local Agency InWecW Of pr g <br /> 2. TFSTING C® CTOS DMORMATION <br /> Company Name, e /'k- IZ <br /> TzcWiciaaCou&wdng Test: AL�t ,a-J L !C<3 <br /> Cr CSLB r ®SWRCB Licensed Tank Tesw <br /> License 1�ps; VAO 13CO�-ke>CD <br /> Mannfitchver Date T <br /> 3. SUEKY OF TEST RESULTS <br /> COMPOIneut PB= Faff TestedNot C Pace Fad r4at RepairsF <br /> esied Made <br /> 1-t �csu � is C ®34 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> —Z. ❑ ❑ ❑ © ❑ . ❑ ❑ <br /> D 10 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ❑ ' ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ . <br /> ❑ ❑ ❑ D ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, be wtud was done with the waw after completion of usts <br /> e <br /> CERTTFiCATION OF TECBMCL&N RZSMNMLE FOR CONDUCTMG TMS TESITNG <br /> To the best of m,�' ge; the facts maW in dds da=avew are accuram md iaa a viih legal rqu' <br /> � e <br /> Technician's S' e: � e� Date: <br /> d <br />