Laserfiche WebLink
sCB,January 2002 JUN p 9 2004 Page of <br /> SeeOndary,tonta" m ent 'Vesting Repo <br /> 5\f?FRNT HEALTH <br /> This form is intenders-for use by contractors performing periodic testing of FIST secondary S Use the <br /> appropriate pages-'of•this farm to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(tf applicable),should be provided to the facility owner/operator for submitral to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: G'' 2: <br /> Facility Address: <br /> FacTky Ccnstaet: r 4, Plane: <br /> Date Local Agency Was Notified of Testing: CjhY <br /> Name of Local Agency lmV=to'(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CL <br /> Technician Conducting Test: ", <br /> L' y, f <br /> Credentials: CSLB Licensed Contractor C SWRCB Licensed Tank e <br /> License Type: i.-�.&Cb License Number: <br /> . IViza Trsiaiag <br /> Mancifacwrer s Date 1!!' <br /> 3. WWWARY OF TEST RESULTS <br /> campaumt Pass ATNot � ss t PaFag Tested s Alades <br /> YZ 0 0 ❑ ❑ 0 0 <br /> 0 ❑ ❑ ❑ ❑ 0 <br /> ' . `❑ ❑ ❑ ❑ ❑ . ❑ a <br /> j o ❑ ❑ a 0 ❑ <br /> 0 0 ❑ Q ❑ ❑ a ❑ <br /> ❑ . ❑ ❑ ❑ ► ❑ ❑ � ❑ ❑` <br /> ❑ a a 1 ❑ ❑ ❑ ❑ ❑ <br /> a ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> 0 a 0 ❑ ❑ ❑ a ❑ <br /> ❑ ❑ a ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ 1 0 ❑ 0 ❑ ❑ 1 ❑ ❑ <br /> Ifhydrostatic testing was performed,describe what was done with the water ager completion of tests: <br /> tti �;-. ti >� <br /> CERTMCATTON OF TECIMCIAN RESPONSIBLE FOR CONDUCTING TIES TESTING <br /> To tAe best of mar knov4edge,the facts stated in tki=s' are urate and in facld compliance with legal requirements <br /> Technician's Sktsature: �, �� -� '�—_ Date: ?�"{^/ <br />