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Jan 20 05 09: 40a nfflfa-Test (209094-0112 p. 7 <br /> SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of USrsecondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(ifopplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> M orad Uevrcrl 1. FACILITY INFORMATION <br /> Facility Name: A o p-7n> Date of Testing: 03� <br /> Facility Address: 1`1 w t A / n t t <br /> Facility Contact - <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector rfpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION' <br /> Company Name: �AA �J <br /> Technician Conducting Test: <br /> Credentials: ❑CSLB Lice ed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License.Number. c/ <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUMMARY OF TEST RESLTLTS <br /> p Not Repairs <br /> Tested RMade Compose pass Bail <br /> Component Pass Fail Tested Made <br /> ❑ ❑ 0 <br /> ❑ ❑ 0 <br /> ❑ ❑ ❑ <br /> i' � i r 0 ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 1 T <br /> v P <br /> C— <br /> CERTIFICATION OF CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document re acce m full compliance with legal requirements <br /> Technician's Signature:,— /;' ate, <br /> L <br />