Laserfiche WebLink
SWR.CB;January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of USTsecondary 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: re4 k4, Date of Testing- ® ,Z O <br /> Facility Address: 7 2 v <br /> Facility Contact: m h Alp Phone: <br /> Date Local Agency Was Notified of Testing : /.2AV)— <br /> Name of Local Agency Inspector(if present duri g testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Banks&Co <br /> Technician Conducting Test: Adolfo Rivas/Danilo Baez/Carlos Alderete <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: Jaz. License Number:383550 <br /> 71ncoManufacturer Training <br /> n <br /> ufacturer Component(s) Date Training Expires <br /> TS-STS Sump Tester --------------------- <br /> UST --------------------- <br /> usco/Owens <br /> Corning <br /> A.O. Smith/Ameron FRP --------------------- <br /> APT/Total Flexible Piping --------------------- <br /> Containment <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> If] 110 Pi i t� <br /> 7 0&00 <br /> g u X171 3- <br /> I 4d*0_- Le�� 1;we 14XV#6-4, ✓ <br /> ',' ✓ u z-s <br /> ft YO <br /> loo— ✓ <br /> PrDimA 5 um <br /> ® s <br /> 0&AA1t/ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> �,�r,� Fig ¢ ✓e, �- f.�e Fu t <br /> Rd oae E �i i' ~5 w.¢s & <br /> dein, MNI 1441ewl (t ug ,4 ,e T dl'As, �f <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: /.3lzV 7- <br />