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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 /> appropriatepages of this form to report results for all components tested The completedform, 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: µ Date of Testing: —d <br /> Facility Address: g lLwy t-1 O C <br /> Facility Contact: 1 1 Phone: 7p9 qLf 1 - Z!57 lD <br /> Date Local Agency Was Notified of Testing: /n —J 7 — D& © d <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: Pr ffb rd 0 — i ;e S r <br /> Technician Conducting Test: /. 1-P f7 1 (til!!- <br /> Credentials: ❑CSLB Licensed Contractor V,/RCB Licensed Tank Tester <br /> License Type: . License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin4Expiurees <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass gall Not Repairs <br /> Component Pass Fail Tested Made Tested Made <br /> Dt � J �( ❑ . ❑ ❑ ❑ <br /> t. rt x ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ ❑ <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, <br /> thefacts stated/din this document are accurate and in full compliance with <br /> legal requirements <br /> ;71 j/ + U Jn ✓� <br /> Technician's Signature:_ Date: <br />