Laserfiche WebLink
SWRCB.J y 2n*2 Page of <br /> Secondary Containment Testing Report 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:_-' ` Date of Testing: <br /> Facility Address: e' d°d y <br /> Facility Contact: �' ` Phone: v^ > -5 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during t ting): ;,x e <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: _rz - r %o <br /> Technician Conducting Test: <br /> Credentials: WP—SLB Licensed Contractor Q SWRCB Licensed Tank Tester <br /> License Type: . License Number. <br /> Manufacturer Trainin¢ <br /> Manufacturer Components Date TrainingExpires <br /> 3. SUMMARY OF TEST RESULTS <br /> mponent PassFail Not Repairs Component Pass Fait Tested Repairs <br /> Tested Made <br /> z /e 1 ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> �• . :syr :z�.. ❑ ❑ ❑ 0 ❑ 0 0 ❑ <br /> ` / Air ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> AW ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ 1 ❑ ❑ 0 0 ❑ 0 0 <br /> 0 0 ❑ ❑ ❑ 1 ❑ 0 0 <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> 0 ❑ 0 0 0 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ o ❑ <br /> 0 D 0 ❑ 0 ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ 0 0 ❑ <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►ny knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signatures r Date <br />