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y <br /> SWRCB,January 2002 • Page L of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of USTsecondary 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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: DateofTesting: (0 'L6 I6O <br /> Facility Address: SSS ti o 9 h <br /> Facility Contact: t,y o Phone: <br /> Date Local Agency Was Notified of Testing: Za 0 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ei 41S Kc �n 7tlu <br /> Technician Conducting Test: rD { ` 1 <br /> Credentials: ktCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: $k Q j <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expi <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> VOc Z ❑ El $ ❑ ❑ El El bo l ❑ 11El [I ❑ 11❑ ❑ El El El ❑ <br /> ❑ El El 101 ❑ ❑ <br /> ❑ ❑ ❑ El El 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ Cl ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water fter completion of tests: <br /> f <br /> CERTIFIC�OF TECBMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowled .t e ac toted in this document are accurate and in full compliance with legal re irements <br /> Technician's Signature: Date: <br /> �J�� <br />