Laserfiche WebLink
SWRCB, January 2002 Page l of �- <br /> Secondary Contai ent T',estinikeport Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: AmM ®A/® ' Date of Testing: 3 z 7 0 6 <br /> Facility Address: S <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: Iy D(o <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION: ' <br /> Com an Name: jeba A 5 <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type:. <br /> License- umber. <br /> Manufacturer Training <br /> Manufacturer Com onetrt s Date Training Ex ices . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail p Component Pass Fail Tested Made <br /> Tested Made <br /> ❑ ❑ ❑ ❑ <br /> l ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with 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 document are accu5ate and in full compliance with legal redcair meats <br /> Date: <br /> Technician's Signature: <br />