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SWRCB,January 2002 • • Page I of 6 <br /> Secondary Containment 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 completedform, written testprocedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> L FACILITY INFORMATION <br /> FacilityName: t 45 Date of Testing: 11) Z OS <br /> Facility Address: - a S �fj' H An <br /> Facility Contact: g '� S o it Phone: <br /> Date Local Agency Was Notified of Testing: 1 Ds- <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t& 5 / 0„t <br /> Technician Conducting Test: v e( d 5 <br /> Credentials: JCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: If I DS-3 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> ITan k-'I 7 h i ese) ❑ ❑ )4. Tested Made <br /> ❑ ❑ El ElSeCer��4( ' t d2 I �7 '�. ❑ ❑ � ❑ ❑ ❑ ❑ <br /> r?con�st✓ a sf Z ReQ i� I% ❑ ❑ 54 ❑ ❑ ❑ ❑ <br /> R¢ �2StL nV61A,* ,f t ❑ ❑ ❑ ❑ ❑ ❑ ❑ JE Elx ❑ ❑ ❑ ❑El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> { f1,7V9Mw r {p-vt5. <br /> CERTIFICATION OF TECIINICL4,N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the s stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: b 2$ 0 <br />