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Secondary Containment Testing Report Form <br /> This form is intendedfor use by contracts performing periodic testing of UST seconJM5rconlainment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: i Date of Testing: 6//7 /o4 <br /> Facility Address; K7c) t(Z3/111� E Gst T4fmP 64- <br /> Facility <br /> -Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(fpresenl during testing): <br /> 2 TESTING CONTRACTOR INFORMATION <br /> Company Name: Fc CdA — E5T <br /> Technician Conducting Test: 7�7"E IVIAel"el <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License.Number. 0 6. <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> OL X ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> I X I I 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> 11 [1 El ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> I�T <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the acts stated in focument are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />