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FROM :B.Z.SERVICESTATION MAINT )NCE FAX NO. :916 371 2540 Tul. 21 2006 01:52PM P2 <br /> // �. <br /> SWRCB,January 2002 Page I of�Q <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing perlodlc testing of UST secondary containment systems. Use the <br /> appropriate pages of this-form to report results for all components tested. The completed form, written test procedures, and <br /> primoutr from tests(fopplicable),should be provided to the faellky owncr/operatorfor submittal to the decal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility N ane: ov mow._.. n• o\C:kcF Date of Testing: 1. l <br /> Facility Address:\-Ipc� y J , Cb.nr4 rf Wj�e <br /> `t) wDFacility Contact: Phone:9M kit) - <br /> Date <br /> ate Local Agency Was Notified of Teadog <br /> Name of Local Agency Inspector(ifpresent during to ting): _ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Nmne: B.Z.Service Station Maintenance <br /> Technician Conducting'I'cst: <br /> ise_d Contractor ❑SWRCB Licensed Tank Tester <br /> Credential-: X CSLB Lim _ <br /> License Type: License Number:433159 <br /> Manufacturer.Train lue <br /> Mauufacuavr 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 Tasted Made <br /> of 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> zt ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> a o ❑ ❑ _..._..__� ❑ ❑ ❑ ❑ <br /> q ❑ ❑ CJ 0 ❑ ❑ CI <br /> Cl 0 ❑ 1 ❑ <br /> V` ❑ D - ❑ D D ❑ ❑ <br /> 7'9 e' n ❑ ❑ r ❑ 0 0 ❑ <br /> !r ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> td Z ❑ ❑ 1- ❑ I ❑ o n n <br /> Ifhydrosuulo testing was performed,describe what Was done with the water 01WT completion of tests: <br /> CERTIFICA ON OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my hno the facts jWfed in this document ao ccurate and!n full compliance with legal requiranents <br /> Technician's Signature: <br />