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SWRCB, January 2002 Page_of_ <br /> Secondary Contaiaent Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form 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: qy Date of Testing: [/—;:X, ¢`"J <br /> Facility Address: p a, docs 48414P41 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: e e - r <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION; <br /> Company Name 'O <br /> Technician Conducting Test: ` ..P � e <br /> JV 1 M6 <br /> Credentials: ❑CSLB License Contractor CB Licensed Tank Tester <br /> License Type:. License Number: cj /�15 <br /> Manufacturer Training_ <br /> Manufacturer COM1301 Date Training;Exves . <br /> 3. SUNINIA.RY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> f ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with thewaterafter completion of tests: <br /> Uc � er )44 1L9 �C Lf �-* tN <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accu ate and in full compliance with legal requirements <br /> Technician's Signature: 02 Date: �" "� <br />