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SWRCB, MAY 2002 Page of <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name. �' z e y-- Date of Testing: /.;Z— .27 p-x— <br /> Facility Address: �� ©G t1 9S <br /> Facility Contact: �� �/ Phone: d — ZZS <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ACCU-TEST C 5 3 o} 7 5-5 — <br /> Technician Conducting Test: ELDON HATHAWAY <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: 1002 <br /> Manufacture Training <br /> Manufacturer Componentfsl Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Pass Fail Not Repairs component Pass Fail Not Repairs <br /> Component Tested Made I� Tested Made <br /> 0 .1 ❑ ❑ �2- ❑ y ce f' ❑ a ❑ ❑ <br /> ;0`Z ❑ ❑ ❑ / Z ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> res, <br /> ZZ/0 ❑ ❑ 13 ❑ ❑ ❑ ❑ ❑ <br /> z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ © ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ E-11111 ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done w' the water after completion of tests: <br /> WATER WAS PROCESSED <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 requiremenfs. 2 2003 <br /> INVIKuNMENI <br /> FEF AT/SF-,'W'i--S <br />