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SWRCB,January 2002 • <br /> Page i of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested. Thecompleted form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> MLocal <br /> : x <br /> ss; Date of Testing: Z -- t/— <br /> D y D Gc1- T t�9nJC <br /> ct: I IGF/t-Z E <br /> ency Was Notified of Testing: Z_ a0%JECN <br /> : (42 _ O <br /> Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: p U17a C/�J <br /> Technician Conducting Test: {��� <br /> Credentials: DtSLB Licensed Contractor <br /> ❑SWRCB Licensed Tank Tester <br /> License Type: //#Z_yh 9$72( SZSL <br /> � G-/D License Number: 6 <br /> Manufacturer Manufacturer Trainin <br /> Com onen s Date Lr6ming Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Not Repairs <br /> Pass Fail Tested Made Component Pass Fail Not Repairs <br /> N �. ❑ ❑ ❑ Tested Made <br /> f� El [I EEl <br /> l ❑ ❑ <br /> W. ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 11 El Ll ❑ ❑ ❑ <br /> i✓D ❑ P ❑ ❑ <br /> N S7-P -CAkm P v F1 11 ❑ ❑ F-1 El <br /> w"p 0' ❑ ❑ ❑ <br /> w . P� Sttrw 1° V ❑ El ❑ ❑ ❑ F-1 ❑ <br /> U„ll.b UD(!., ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Al W 13 ❑ ❑ ❑ <br /> ❑ ❑ ❑ 11 El ❑ ❑ <br /> Wriaray ❑ ❑ EJ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> jV710) , , 4/'o-W <br /> CERTIFICATION OF TECDTIICLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: /�/J � �}y^� Date:_ 12 -11-07 <br />