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S WRCB,January 2002 <br /> Page_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 afthis form to real results <br /> P for alp components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facilityowner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> rof <br /> : ,� •, <br /> ss: Date of Testing: — �f!QE <br /> tx: /4�7Co^rl� Phone: <br /> ency Was Notified of Testing: <br /> l AgencyInspector(ifpiesent during lestingj- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Cham ion Precision Testing,Inc. <br /> Technician Conducting Test: All Service Technician# <br /> Credentials: X 'SLB Licensed Contractor ❑S WRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 848150 <br /> Manufacturer Maaufaetarer Training <br /> Com onent s Rafe Ttainia Ex ices <br /> 3. _SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Reps;n <br /> Tested Made Component Is Fag Not Ra <br /> Tested Mada <br /> E D ❑ C ❑ ❑ ❑ <br /> O ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ O ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> fff ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i <br /> or 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> CfiR!r ❑ ❑ ❑ ❑ <br /> 3/ /r L� ❑ ❑ ❑ ❑ ❑ ❑ D <br /> s 6 /r �' ❑ ❑ Li ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance wieth legal requirements <br /> Technician's Signature: _ _.__ Date: <br /> t 'd 9i CLLZ69I8 uogsny yy101 eETlii 90 10 ^oN <br />