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SWRCB.January 2002 • • <br /> Page_of_ <br /> Secondary Containment Testing Report Form <br /> 1 his forst is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of chis fibrm to report results for all components tested. The completed form, written test procedures, and <br /> printoutr�rom tests(ifapplicahle). should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Vjr C'D Date of Testing: <br /> Facility Address: �s ' <br /> Facility Contact: Phone: 9 _ <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during tesitn <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: Service Technician# _ <br /> Credentials: X CSLB Licensed Contractor S WRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 848150 <br /> Manufacturer Trainin ^ <br /> Manufacturer Com onent(s) Dale Tramin g Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Not Repairs <br /> Tested Made p Pass Fail Tested Made <br /> x ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> IJ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ C] ❑ P <br /> ❑ ❑ ❑ ❑ ❑ rel <br /> W47� <br /> ❑ ❑ LlLI II 1]❑ ❑ ❑ ❑ I1 fl C:I <br /> S 1 & x ❑ ❑ ❑ ❑ LI ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ LI I1 11 <br /> If hydrostatic testing was performed,describe what was done with tate water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the acts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signalt Date: <br />