Laserfiche WebLink
: SWRCB,January 2002 <br /> Page i' 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(f applicable), should be provided to the facile weer/operator for submittal to the local regulatory agency. <br /> 1. FACILITY O TION <br /> Facility Name: G4 S 1-&ate of Testing: 12,11 <br /> Facility Address: 4(UCS G4,5- - y; 11. e t,, 5 o►^ <br /> Facility Contact: 2 r c (c Phone: Z,v �¢6 3 <br /> Date Local Agency Was Notified of Testing: t ? 14) U $ <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 4 V,l r <br /> Technician Conducting Test: 1 Q,, u,, h P-, u K J-V , <br /> Credentials: 11 CSLB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type: ` ccAt °�° License Number: l�-t 12, 6) ,;i,-e t",y[T`�f�O -t t'C � S ►/ <br /> Manufacturer Training <br /> Manufacturer Component(s) Tram;- Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass fail Not Repairs <br /> Tested Made Tested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> WAI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V (5t �a.Z ❑ D ❑ ❑ ❑ ❑ ❑ <br /> Lk � =-� c �'` ❑ D ❑ ❑ ❑ a ❑ <br /> uk 9 �1-7 S 8 0 ]LIJ <br /> If hydrostatic test in was performed,describe what was done with the water after completion of tests: <br /> 14 1 E `r- <br /> .S C,t, S+.c f J� ��.�� �°�. ' '�Lt C[.'.( Loe @t e - .t <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In this d� menI are accurate and in full compliance with legal requirements <br /> Technician's Signature;' r_. , _ <br /> ,..�� � a. � Date: Z-�/ � �`) <br />