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1 0 0 <br />SWRCB, January 2002 Page _l_ of 2 <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 (:f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />Com any Name: California Petroleum Equipment Inc. <br />Technician Conducting Test: Bryce Ruschhaupt <br />Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: A, B, C-10, C-61-1340, Haz License Number: 432613 <br />maaafactarcr aluff <br />Manufacturer Co t s Date Training Expires <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 knex4edge, the facts stated in this document are accurate and in full coMpikince with legal requirements <br />4 --z <br />Technician's Signature: Date: -3-14-12 <br />MCI <br />W � <br />Regular n,' Secondary <br />Containment <br />mom= <br />..—m. <br />..®m... <br />oma <br />m <br />mm <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 knex4edge, the facts stated in this document are accurate and in full coMpikince with legal requirements <br />4 --z <br />Technician's Signature: Date: -3-14-12 <br />