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Page of— <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> i his 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 /> l <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local reguatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: — —D 3 <br /> Facility Name: G <br /> Facility Address: 3 3 5— <br /> Facility <br /> — <br /> Facility Contact: C C <br /> XL— <br /> ENalmeof <br /> al Agency Wa�Inspector <br /> d of Testing: / <br /> Local Agency (+f present during testing): Qrt�� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: ►'vl S �� <br /> CSLB Licensed Contractor I'SWRCB Licensed Tank Tester <br /> Credentials: <br /> G S/3 License Number: <br /> License Type: Q <br /> Manufacturer TraininS <br /> Manufacturer <br /> Com onent(s) Date Trainin Ex fires <br /> r� <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> P s Fail Not Repairs Component Pass Fail rested Made <br /> Component Tested Made <br /> ° ❑ ❑ ❑ ❑ <br /> ❑ <br /> ❑ ° ❑ ❑ <br /> ED g _ ❑ ° ❑ ❑ ❑ ❑ <br /> ,GP `z l ❑ ❑ ❑ ° ° ❑ ❑ <br /> ° ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ° <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fac ated in this document are accurate and in full compliance with legal requirements <br /> Date:_11(— l - C <br /> Technician's Signature: <br />