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SWRCB,January 2002 Pagc_of <br /> Secondary Containment Testing Report Form — Spill Buckets <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The complexed 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: r ® Date of Testing: 1 - 2c-f - <br /> Facility Address: (cI7S t,/ 1--_d l/e C.L ,:,e <br /> Facility Contact: I Phone: <br /> Date Local Agana Was Notified of Testing: ✓ <br /> Name of Local Agency InspccWr(+fpresent during testing): !Dt?A-� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Cmdudmg Test: Ed Stearn <br /> Credentials: X CS1 LK=sed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 804890 <br /> Mmafrcturer Trainiae <br /> Manufacture Co neugsl Dam Traung Expares <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pas Fin Not Repairs Tested Made Compoaeat Pas Fait Not Rqwirs <br /> Tested Made <br /> 52 Pe (( ❑ ❑ ❑ ❑ ❑ ❑ <br /> e. Pse L e ( 0 0 0 ❑ 0 ❑ 0 <br /> ❑ ❑ ❑ ❑ 0 ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> 0 ❑ 0 ❑ 0 0 0 ❑ <br /> 0 ❑ ❑ 0 0 0 ❑ 0 <br /> ❑ ❑ 0 ❑ 0 ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water alta completion of tests: <br /> © n file- In 17 fury <br /> CERTHIICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the beat of my kxom edges the fans swedd in thiss document are accurate and in fuU camp/lance with legal requiretnexas <br /> Technician's Sigoahue: ,efo'f Date: <br />