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SWRCB, MAY20b2 Page 1 of S <br /> Secondary Containment Testing Report Form — FINAL DRAFT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: -S 2 <br /> Date of Testing: <br /> Facility Address: t/31LCA g 'rr 12 C <br /> Facility Contact: Al,G K®ST -A Phone: ® — <br /> Date Local Agency Was Notified of Testing: loz ��(} <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 `3 U) 255-12ZE, <br /> Credentials: ❑ CSLB Licensed Contractor [SWRCB Licensed Tank Tester <br /> License Type: License Number: 1002 <br /> Manufacture Trainin¢ <br /> Manufacturer Component(sl Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Pass Fad Not Repairs <br /> Component Pass Fail Tested Made Component Tested Made <br /> EST #� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> rr �Q <br /> El <br /> ❑ El El 11 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a x7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> A ❑ ❑ ❑ El EJ El El <br /> EJ El El ❑ El ❑ El El <br /> 0 El 0 El <br /> c1 G `_3 ❑ ❑ LL ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> WATER WAS PROCESSED <br /> CERTIFICATION OF TECHNICIAN RESP SHLE iFOR 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 /> DEC 16 zw <br /> ENPERM�M SERVICES H <br />