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SINRCB, MAY 2002 <br /> Secondary Containment Testing Report Form — Page °f � <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment DRAFT <br /> Pages of this form to report results for all components tested. The completed form, written test procedures, d Use he appropriate <br /> (if applicable), should be provided to the facility ownerloperator forsubmittal to the local regulatory agency, <br /> F from tests <br /> L FACILITY INFORMATION <br /> Facility Name: <br /> Facility AddresMNftifj,--d <br /> '� � Date of Teesting:dFacility ContacPhone: _Date Local Ageug:Nance o£Local nt duringtesting): <br /> 2. TESTING CONTRACTOR FORMATION <br /> Company Name: ACLU-TEST <br /> Technician Conducting Test: ELDON HATHAWAY �� SS— <br /> Credentials: CSLB Licensed Contractor 9SWRC.B Licensed Tnnk Tester <br /> License Type: <br /> License Number: 1002 <br /> Manufacturer Manufacture rain`n <br /> !L—�Mponent(sl <br /> Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass pall NotRcpuirs <br /> 1�sted Made Component Pass pail Not Repairs <br /> ❑ ❑ fisted Made <br /> ❑ C�'{' ❑ <br /> El R ElF-1 ❑ <br /> -;*z. ❑ a ❑ ❑ <br /> rR El El <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> El 0 101 Ej <br /> ❑ ❑ ❑ El El El Ej <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 0 ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests.- <br /> WATER <br /> ests:WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements. <br /> � .d aTLfr- E[3B (BOi;a �I�1N3� 13f SaNddS ow d <br /> ao : T o za 1'a Dec <br />