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SWRCB,January 2002 ./ Page j—of 2 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use die <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 thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: eDate of Testing: - C. ' <br /> Facility Address: 1 L t - <br /> Facility Contact: Phone: C' ,! _ '%< <br /> Date Local Agency Was Nofified of Testing <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING-CONTB4CTOR INFORMATION <br /> Company Name: t ' o C • .- <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: Z License Number: C jC <br /> Manufacturer Training <br /> Manufacturer Co onent s Date Traininp Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> f= I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> e t~ o41 1 - i lne <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,th acts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />