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SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form — Spill Buckets <br /> This form is intended for use by contractors performing periodic testing of U.W secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(iapplicable), should be provided to the facility awner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date of Testing: 9 p <br /> Facility Address: Lj <br /> Facility Contact: �,7`5 Ph <br /> Date Loral Agency Was Notified of Testing: <br /> Name of Local Agency Inspector[ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: _ .n <br /> Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 804890 <br /> Manufacturer TrAnin2 <br /> Manufacturer Component(s) Date Training E ices <br /> 3. SUA04ARY OF TEST RESULTS <br /> Component Pass Fad Not Repairs Component Pass Fat? Not Repays <br /> Tested Made Tested Made <br /> @11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ . <br /> ❑ ❑ ❑ ❑ ❑ ❑ !, <br /> ❑ Cl ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ n ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0E01 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECII11IICIAN RESPONSIBLE FOR CONDUCTING THLS TESTING <br /> To the best of my knowledge,the fads stated in this document are accurate and in full compliance with legal requirements <br /> n <br /> Technician's Signature: i/ / Date: t�` ,'S 0 <br />