Laserfiche WebLink
n'rRrw9 <br /> page I n f 8 <br /> Secondary Containment Testing Report Form <br /> This fond is intended for use by confrdctors perfonrrino periodic testing of LIST secondary containivent systems. Use the appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable),should <br /> be provided to the facility ownerloperator for suomitta)to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: �� Gate of Testing: <br /> Facllity Address; <br /> .....rv.__.. -. .ice <br /> Facility <br /> Contact" a _ Phone: <br /> Gate LoGai Agency Was Notified of Testing.,-­. <br /> Name of Local Agency Inspector(if present during testing): p �� t <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name: PPIC Compliance Systems <br /> Technician Conducting Test: ~_ <br /> Credentials: _ 21 CSLB Licensed Contractor C:i SWRCB Licensed Tank Tesler <br /> License Type: .W .......: A N4 �� License Number. 8844.30 <br /> �� �g:F.•. ..•,.' 4;r.1`�.;;;;� k;, },7''.:9�!k3ia�, :a',.:."..:.�rmS1.'f;�4'°Jar: 4=;� •u,;4017-21-19-1 <br /> : �' r aA '"�°� <br /> Y. °!L .4'`p'� i•.• 'aw,;:.i,.'� w�.1.:5?'. ._I{_ „ai:. �`"^M.Y^.+Fw.w.,...x..$f1 <br /> Manufacturer Training <br /> MandfacturerCom onent s hate Training Ex fires <br /> 2_..,.._L ..,._........ ....... <br /> _.____.___.._.,_.....__ <br /> r^�r .(�____...,___ Ctc../ad u�d! �f's1�•� dna .d...� ____..__ --- <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs ��a i Not Repairs <br /> Component Pass' Faii Component Pass Fall <br /> Tested Made P Tested bade <br /> U J <br /> _ CJ C] <br /> 1-2. <br /> d ; i _r •;a rl �t � _ i:: <br /> e .�..._..�.^..... ..�....^..,i., <br /> - 0 <br /> .�-� - ----........ <br /> ...,....,........._.__._..... ..._......_:..............................._...._..... . <br /> J . �. .m <br /> If hydrostatic testis was errormed,describe what done daith the water after col....,P.__Ietion of resist <br /> ---fir•--� was _..._____..,..._ �. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, th�cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: eA !-.l Date: <br /> TT/Z0 39Vd 71IH >iOf1H0 EZ96EGET99 89:80 6002/b0/ZO <br />