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SWRCB, January 2002 rage_U _ <br /> Secondary Contaiftent Testing Report Form <br /> This form is intended far use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: "0, v e Date of Testing: -q— to —O�d <br /> Facility Address: N r— <br /> Facility Contact: <br /> Phone: <br /> Date Local Agency Was Notified of Testing : — Z — 0 42l <br /> Name of Local Agency Inspector(tfpresent during testing): i�LE v Ly <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: C' r a X fi I <br /> Technician Conducting Test: -P Imo. • 5 ted Yet f) <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License Number: 1� <br /> Manufacturer Training <br /> Com Onent s Date Training Expires <br /> Manufacturer <br /> 3. SLTMMAR`st OF TEST RESULTS Not Repairs <br /> Paas Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> 5A A— taco Pr f� a ✓ ❑ ❑ ❑ ❑ <br /> rt. t ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> t 4-7¢tY a yr { s <br /> �'e`C ��Yh Tom' <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thefacis stated in tlnls document are accurate and in fill compliance with legal requirements <br /> Technician's Signature:, y <br /> �1 / f ? Date: Fa — <br />