Laserfiche WebLink
Nov 28 12 07: 38a Elite IV Contactors 12094616342 p. l <br /> SWRCB,January 2002 Page I of 7 <br /> Secondary Containment Testing epo:r Form �` ;4=s"oci'n� <br /> This form is intendedfor use by contractorsperformingperiodic testing of USTsecondx:• c.ntainment systems. Use the <br /> appropriate pages of thisjorm to report results far all components tested. The completed.fc ?%written test procedures, and <br /> printouts from tests(if applicable),should be provided.to the facility owner/operator fors•e1 �,ittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION _ <br /> Facility Name: Date c .'resting: � ♦Z <br /> Facility Address: c- t. r <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: _ <br /> Name of Local Agency Inspector(rf present during testln , i 1�„ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: E 11:�!. ' r{ - ® . .. <br /> Technician Conductin Test: , <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank I .z;ter <br /> License Type: Wn 7 License Number: 1::7 a C ' <br /> i� t <br /> Manufacturer Training <br /> Manufacturer Component(s) _ Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS _ <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 57 ❑ ❑ 0j:11--lociQ X ❑ ❑ ❑ <br /> 6 L ❑ ❑ ❑ and 4 U,J :. ❑ ❑ ❑ <br /> ❑ d ❑ ❑ ❑ ❑ ❑ ❑ <br /> D 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ElEJLJ <br /> If hydrostatic testing was performed,describe what was done with the water after completion )f tests: <br /> _...._-TERTIF'ICATION t1F'T EUS <br /> NI�;IAZZ�ESII' NSISI��6R�ONIJUC:7T i.�THISTESTING— __ . <br /> To the best o *no*W — — — <br /> tray ,. dgei-tli staled wPrt t are accurate ull ciavr, -�aanee ivt77t7egal requiremenis <br /> Technician's ' Date <br /> EcEwED <br /> , <br /> NOV 22012 <br /> SAN JOAQUIN COUNTY <br /> °,e L,r±.; .va..,t.•.., . . ,�.' 4r s,a !!} ', , <br /> ENVIRONMENTAL <br /> HEALTH DEPAWMENT <br />