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' May 05 04 03: 22p • (2096749-0112 p. 6 — <br /> ragc <br /> S WRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This form is iniendedfor use by contractors performingperiodic testing of UST secondarycontainmdnt systems. Use the <br /> appropriate pages of thisform to rdport results for all components tested The completedform, written lest procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator far submittal to the local regulatory agent <br /> 1. FACILI'T'Y INFOT2MATION <br /> Date of Testing: <br /> Facility Name: <br /> Facility Address: Phone: <br /> Facility Contact: <br /> Date focal Agency Wes Notified of resting <br /> Name of Local Agency Inspector(ifpreseN during tdsring): & <br /> 2. TESTjVa'CONTRACTOR INFORMATTON <br /> Company Name• rI ATr <br /> Technician Conducting Test •e* CJ• t (� ✓ir <br /> Credentials: ❑CSLB Licensed C nttsctor SWRCB Licensed Tank Tester <br /> Liceane Type:. License Number: —If <br /> anufacturer Trainin <br /> Date <br /> Manufacturer <br /> Com on s Train n }ix ira; _ <br /> 3. S OF TEST RESULTS Not l:apal- <br /> Pam F'an Not Repairs Component Pura Fan T� ted Mad <br /> Component TestedMade <br /> ❑ . ❑ ❑ ❑ <br /> " „ ❑ ❑ 0 ❑ <br /> S <br /> 0 ❑ 0 ❑ <br /> ❑ ❑ ❑ ❑- <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ o <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: r <br /> �flir c or— (\ C- 0 /0 = — <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> ro the best ofmy knowledge,the facts stated in this document are acethate and in full comptlance with legal requtrements <br /> Technician's Si aiure: (//J <br />