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SWRCB,January 2002 Page / of <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 completed form, written test procedures, and <br /> printouts from tests (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ssoei�-�- Date of Testing: 1l Q <br /> Facility Address: <br /> Facility Contact: zz5�� Phone: O <br /> Date Local Agency Was Notified of Testing : /01.3/A0 <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 RivaslDanilo Baez/Carlos Alderete <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: AlHaz• License Number:383550 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS-STS Sump Tester --------------------- <br /> Modern LIST - --------------------- <br /> Welding/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 Malde Tested Made <br /> r AA"IAW— <br /> Y ✓ <br /> u � <br /> G�45o i,t� S <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> I�s�r' �wcr� IN45 �C2L' �i7 tae rcQ r <br /> 7'-4e n! <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: ,G' F cr h Date:-lIze/o Z <br /> l/ <br />