Laserfiche WebLink
i6ECOVED . &6 <br /> S W RCB,January 2002 APR 2 7 2'010 Page -� of <br /> Secondary Containment Testing R HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST second con! inment ICES Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: L4 q i S a r US j Date of Testing: 2(D 1 () <br /> Facility Address: q 3-j C-r1L S Z t <br /> Facility Contact: Cit vim. Phone: <br /> Date Local Agency Was Notified of Testing: Z—z.Z — 10 bP <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: j v, <br /> Credentials: ❑CS LB Licensed ontractor WRCB Licensed Tank Tester <br /> License Type: , le_ -e.pe' License Number: /Z,la,. -ee-. <br /> C ..:. <br /> D 1 <br /> Manufacturer Training <br /> Manufacturer om onent s Date Training,Ex <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> � ce, ud ► l`#a ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ids ►� -1 ❑ ❑ 0 ❑ ❑ 1 ❑ ❑ <br /> o-F❑ 1 ❑ 1 0 O 0 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ D D ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ a ❑ ❑ ❑ <br /> If hydrostatig4esting was performed,describe what was done w' the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated In this do ent are accurate and In full compliance with legal requirements <br /> Technician's Signature: �- l �` Date: <br /> r'• <br />