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S"VRCB,January 2002 Page ! of -Z- <br /> Secondary <br /> Secondary Containment Testing Report Form , <br /> This firm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report re.5wits for all components testers The completed form, written test procedures, and <br /> prtntouts from tests(if appiicahle), should ae provukd to the facility owner'operator for.svhmittal to the local regulatory agency <br /> 1. FACILITY INFORMATION <br /> Facility Name: C-.K+r j-t- Lr v�' A Aca^) Date of Testing: <br /> Facility Address: -=2 7 L ( <br /> Facility Contact: I Prone: <br /> Date LixW Agency Was Notified of Testing <br /> Mamie ofLocai.Agency Inspector(if present during testing): � � k <br /> 2. TES'T'ING CONTRACTOR INFORMATION <br /> Company Name; :-2 ; f 2 s <br /> Techs ieiau Conducting'fest: j tj L_ I t�Q' <br /> Credentials: (CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> Licensee Type: `�L��G License Number <br /> Manufacturer Training <br /> Manufacturer Co onent(s) Date"Trains F?Epires <br /> 3. SUMVTARY OF TEST RESULTS <br /> Component Fars Fait <br /> Not Repairs Component V Pass Fad Not Repairs <br /> Tested Made � Tested; Made <br /> -r/41V it- 45&cK_'T— ❑ Q ❑ ❑ ❑ ❑ ❑ <br /> Q ❑ ❑ Q ❑ Q <br /> tt ❑ Q ❑ ❑ ❑ ❑ <br /> Q Q 1i ❑ Q 0 ❑ 9 <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> © ❑ ❑ ❑ ❑ ❑ ❑ C <br /> ❑ ❑ ❑ ❑ C ❑ Q <br /> ❑ ❑ J Q ❑ a Q Q <br /> If hydrostatic testing was performed, describe what was done with the seater ager completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of`trry knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technidan's Signature: ante: r_--- <br />