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Dec 1,6 09 08 : 20a Elite IV Contactors 12094616342 p . 3 <br /> _ , i • <br /> Page_�_of 9, <br /> SWRCB,January 2042 <br /> Secondary Containment Testing Report Form <br /> Thisform is intended for use by conts-actors performing periodic testing of UST seconda,;v 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(:f applicable), should be provided to the facility owner%operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: - <br /> FFacilityCon <br /> : <br /> ess: _ — <br /> ct: Phone: <br /> gency Was Notified of Testing DA <br /> l Agency Inspector(if present Barring testing: <br /> NJ AP M A 111 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:( License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training E� lies <br /> I20 <br /> 9, ft=== <br /> 3. SUNMARY OF TEST RESULTS _ <br /> Not Repairs Repairs <br /> Component Pass Fail Component pass Fail Tested Made <br /> Tested Made <br /> ❑ ❑ ❑ ❑ a ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Cl ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> p ❑ ❑ G ❑' ❑ ❑ <br /> Cl ❑ ❑ ❑ ❑ ❑ 4� _ <br /> C ❑ ❑ D ❑ ❑ <br /> II ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Cl ❑ <br /> ❑ Cl ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 facts stated in this document are accurate and in full compliance with tegal requirements <br /> Technician's Signature: Date: \? - I I_ <br />