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SWRCB, January 2002 Page of <br /> Secondary Contai _lent 'I'esting'Report Form! <br /> This fornz is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> gppropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts fi-om 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: fir. r .,� ie:� Date of Testing: <br /> Facility Address: '', F� I ` =►' <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : 4" —lJ eT 4) 1 <br /> Name of Local Agency Inspector(rf present during testing): ' ;!,, _," I, l , <br /> 2. TESTINGCONTRACTOR INFORMATION: <br /> Com anv Name: -C t` -6# — <br /> Technician Conducting Test: f_\/J--p 17. Ij r kb-) vk?, .) <br /> Credentials: ❑CSLB Licensed Contractor RCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Componq-+(sN Date Training Expires . <br /> 3. SUMMARY OF TESTVr-!1MTS <br /> Not p Not Repairs <br /> Component Pass Fail Tested Repairs <br /> Component Pass Fail Tested Made <br /> ❑ ❑ ❑ ❑ <br /> a�1. El El 11 ❑ <br /> 71� .lir <br /> El 0 El <br /> P ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> lw � Er—3kx , �Q1J dY� �L2t � � � Ql ` 1J- r0 <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 )Pith legal requirements <br /> Date: <br /> Technician's Signatures /] <br />