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,Nov it 11 08: 05a Elite IV Contactors 12094616342 p. 3 nn <br /> SWRCB,January 2002 Page t of L <br /> Secondary Containment Testing Repoi is Form <br /> This form is intended for use by contractors performing periodic testing of UST seconda:y :ontainment systems. Ilse the <br /> appropriate pages of this form to report results for all components tested The complete, ',rm, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for s bmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION _ <br /> Facility Name: `��"'� Date _•f Testing: <br /> Facility Address: T5 I <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: av 1 , 21M <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATIONA <br /> Company Name'"' __._ <br /> Teclnician Conducting Test: � )gj1 ,t i-T _ <br /> Credentials: �&CSLB Licensed Contractor 0 SWRCB Licensed Taal 'rester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent(s) _ Date Training Expires <br /> 20 <br /> 3. SUIM Y OF TEST RESULTS _ <br /> Not RepairsMot Repairs <br /> Component Pass Fait Tested' Made Compoue t Pass Fait Tested Made <br /> t ❑ ❑ ❑ — 0 ❑ ❑ ❑ <br /> 0 1:1 0 ❑ _ ❑ ❑ ❑ ❑ <br /> 0 1 ❑ 0 , ❑ - 0 ❑ C. 0 . <br /> ❑ ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> o ❑ 0 ❑ _ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 0 ❑ ❑ ❑ <br /> ❑ ❑ 0 0 _ ❑ ❑ ❑ ❑ <br /> 11 El 11 D <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 0 ❑ ❑ ❑ ❑ ❑ 0 <br /> ❑ 0 ❑ ❑ - 0 ❑ 0 0 <br /> ❑ ❑ ❑ ❑ ❑ 0 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after complei an of tests: <br /> P ;5t ;1r �I C15 t'` Cci''dLc± fie4t rd _ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR COND134 'TING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in fu f/ ermpliance with legal requirements <br /> Date:( <br /> Technician's Signature: tr` <br /> Jt 1 <br />