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S WRCB,January 2002 Page_of_ <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contactors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts fiom tests(if applicable), should be provided to the.faciliiy owner/operolo•for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: e) !sting: 77 r —e <br /> Facility Address: 2 C OAJ LTJ nl <br /> Facility Contact: )011Ai SG e. r Phone: 2-6q-6 eV -33 3 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector(ifpresenr during testing): ,,j Joa G' — <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: tv1 <br /> Technician Conducting Test: c/S <br /> Credentials: PIC Licensed Contractor iKSWRCB Licensed Tank Tester <br /> License Type: ffFtZ —/ License Number. 5 -09 <br /> Manufacturer Trainine <br /> Manufacturer Com onent(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Re airs <br /> Component Pass Fail Tested Repains Made Component Pus Fail Tested Made <br /> 7 r. ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> •� �,� ❑ ❑ ❑ <br /> ep <br /> i v� a� oa❑❑❑ ❑❑❑ ❑o❑ ❑ ❑ <br /> C1 13 ❑ ❑❑❑ ❑❑ <br /> o ❑ ❑ ❑ ❑ <br /> ❑❑ ❑ ❑D— <br /> Q13 0 ❑ ❑ ❑ ❑ <br /> ❑ C]❑ <br /> ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 01 ❑ ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> cu <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, thelapis stated in this document are accurate and in full compliance with legal requirements <br /> �, Dater <br /> Technician's Signature:_ <br />