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SWRCB, MAY 2002 • • Page l of <br /> Secondary Containment Testing Report Form - FINAL DRAFT <br /> This form is intended for use by contractors performing panodic testing of UST secondattry containment� soced�re; and printout from rests <br /> pages of this farm to report results for all components tested The completed form, P <br /> (if applicable), should be provided to the facility ownerloperotor for submittal to the local regulatory agency <br /> 1. FACILITY INFORMATION Date of Testing: -]-03 <br /> Facility Name: GA 5 ne <br /> Facility Address: s.. av a /Ce d <br /> Phone: <br /> Facility Contact: <br /> Dale Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ACCU-TEST <br /> Technician Conducting Test: ELDON HATHAWAY <br /> Credentials: ❑ CSLB Licensed Contractor 5f SWRCB Liwused Tank Tester <br /> License Number: 1002 <br /> License Type: <br /> Manufacture Trainine D to Tra in Bxoires <br /> Comonent(a <br /> M tact rer <br /> EST <br /> 1 <br /> 3. SUMMARY OF TEST RESULTS Nor Repairs <br /> Not Repai. Com neat Pass Fen T . , Made <br /> Component F°°r FAN 'haled Made Component <br /> fpr �p- <br /> ❑ El Ot G ❑ ❑ IOC <br /> a z ❑ ❑ bi�- Uo c +# 3 1 fa3 ❑ ❑ �L <br /> 'Po ❑ uoG7_y � o o <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ <br /> F-1 <br /> ❑ ❑ e fEl 1:1 El <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 11 El <br /> ❑ El ❑ 11 ❑ ❑ <br /> If hydrostatic testing wes performed,describe what was done with the wa a r completion of t <br /> WATER WAS PROCESSED <br /> compliance with legal rega' <br /> CERTIFICATION OF TECHNICIAN RES NSIBLE FOR CONDUCTING THIS TING <br /> To the best of my krrowledgg the facer stated in this document are accurate and in full , <br /> FEB 1 8 2003 <br /> CNPErIIHEALTH <br /> /SERV CES <br /> RM <br />