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SWRCB, MAY 2002 _ Page I of 5 <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: <br /> Date of Testing: —- —Q <br /> Facility Address: 2q-SI EA-Sr O C k C Ow. 9g OS <br /> Facility Contact: , o 'r'R Phone: 0 — <br /> Date Local Agency Was Notified of Testing: I() -1 p <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 63 0) 2 5-5-127F) <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: 1002 <br /> Manufacture Trainine <br /> Manufacturer Co ononent(sl Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsFars Fail Not Repairs <br /> Component Pam Fail Tested Made Component Tested Made <br /> Yi (� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El EJ El El ElEl <br /> ER ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El❑ ❑ ❑ El El <br /> ❑ El El ❑ El ❑ El El <br /> # —Z 19 ❑ E1±1:1 ❑ ❑ ❑ El❑ ❑ ❑ El ❑ ❑ ❑ <br /> El Ell ❑ ❑ ❑ ❑ ❑ ❑ <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 SIBLE FOR 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 0 5 2002 <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICES <br />