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SWRCB,January 2002 of <br /> Secondary Containment Testing Report Form p g 2008 <br /> This form is intended for use by contractors performing periodic testing of UST secondary coMir <br /> ,sy tie(ws., Use the <br /> appropriate pages of this form to report results for all components tested. The completed for�3itt'S�acri� and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submiiwl� tory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: E-o-, Date of Testing: <br /> Facility Address: G- ' <br /> Facility Contact: Phone:' V <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(':(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: Keith Huston Service,Technician# 5262044UT <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 848150 <br /> Manufacturer Training <br /> Manufacturer Com onent sy• Date Training 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 /> �r e'i ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> �� �/� e� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �' /� r� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> �- �� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 411 <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 /> Technician's Signature. aw � Date: ,10 ��� <br />