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' SWR1C8,January 2002 �� Page � of <br /> Second Containment Testing R.epL�'t 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 (f applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: LkejeaZSoC�,4-ff —�, Date of Testing: J/ 2 <br /> Facility Address:jg17 <br /> Facility Contact: `I 1 5 `,¢ Phone: 2o <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Banks &Co <br /> Technician Conducting Test: Adolfo Rivas/Danilo BaezlCarlos Alderete <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A/Haz. License Number:3$3550 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS-STS Sump Tester --------------------- <br /> Modern UST <br /> --------------------- <br /> W eld in g/Trusco/Owens <br /> Corning <br /> A.O. Smith/Ameron FRP --------------------- <br /> APT/Total Flexible Piping __________ <br /> Containment <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> -dt/ ✓ <br /> Y D el 1,-y <br /> pr�s�'' S`r'!! 7�' l✓ <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 legal requirements <br /> Technician's Signature: 9��� ,�j Date: 1 �lO <br />