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SWRCB, January 2002 Page /' of,-'l— <br /> Secondary <br /> f oZ, <br /> Secondary Containment Vesting Report Form <br /> This form is intended for use by coi7tractors 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 lest 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 /> b � I Date of Testing: <br /> Facility Name: ()�/ <br /> Facility Address: 1 T- nl r t 6ri <br /> Facility Contact: j 0.6-1, /� � �' Phone�aa 1� J -07 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION; <br /> Com anv Name: 1`dam ' T-,�7 T <br /> Technician Conducting Test: C Df�%`✓ � `-�� <br /> Credentials: ❑CSLB Licensed Contractor �WRCB Licensed Tank Tester <br /> License Type:. License.Number: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Ex ices . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> ComNot Repairs <br /> Component Pass Fail T,,ted Made ponent Pass Fail Tested Made <br /> l l ins d, ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br />