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S WRCB,January 2002 <br /> Secondary ContaI�W,ment 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 /> printoutsfrom tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: —"7 / — 041 <br /> Facility Name: v <br /> Facility Address: (p-;?-oC � $ P— M n � <br /> Phone: :a g W <br /> Facility Contact: py <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comuany Name: -li ' �' <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: . License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Tminine Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component <br /> Pass Fail Tested Made Component Pass Fail Tested Made <br /> �J N .7O ✓� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ o ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> 4 �(" ��lk P U Q/ '10 !XV- Id Li,a t i c "(11 <br /> V <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To tlt.e best of my knowledge, <br /> the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: i / I Y' i-Z E�=° ' -r.�? _ _ Date: 'S� <br />