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S WRCB, January 2002 Page_of_ <br /> Secondary Containment Vesting Report Form 6 <br /> This form is intended for use by contractors performing periodic 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 proceedures,and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> M oracles Chevron 1. FACILITY INF:(F�; <br /> MATION <br /> Faci]ity Name: { „ft f Testing: offFacility Address:Facility Contact: <br /> Date Local Agency Was Notified of Testing :Name of Local Agency Inspector (ifpresent duringtesting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: A <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Lice ed Contractor SWRCB Licensed Tank Tester <br /> License Type: . License Number: <br /> Manufacturer Training <br /> facturer Com onent s Date Training Expires <br /> Manu . <br /> 3. SUNEMARY OF TEST RESULTS <br /> Not Repairs Pass Fail Not Repairs <br /> Component Pass Fail Component Tested Made <br /> p Tested Made <br /> ❑ ❑ ❑ <br /> i4-t si'C-� -t ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> i=L E, El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> t.. a l-4 , n-E e— <br /> ! v ° <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document re acc to a d m full compliance with legal requirements <br /> Technician's Signature: <br /> a ` / �c�ll.a�l_�� Date: <br /> U <br />