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SWRCB, January 2002 ° "Now 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 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 If I <br /> Facility Name: Date of Testing: 02 O y <br /> Facility Address: j t S 57;9-,D <br /> Facility Contact: .kPhone /-oZ�7/' <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector frfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t P5'F <br /> Technician Conducting Test: fj G M M <br /> Credentials: ❑CSLB Licensed Contra for CB Licensed Tank Tester <br /> . License Number: `j <br /> License Type: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Ex ires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fad Tested Made <br /> G J�rtol/ n. 11 . 11 11 11r r $P ,ft rr ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Cl <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> 0 E EO [111 11 11 <br /> ❑ ❑ ❑ <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,thefacts stated in this document are accufate and in full compliance with legal requirements <br /> Technician's Signature: ((// L6+� s�� CJ <br /> Date: <br />