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S WRCB.January 2002 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 of this form to report results for all components tested. The completedform, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the factlity owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FName: Date of Tes[ing: <br /> Facility r7 <br /> Facility Address: Q —0, 6 <br /> Facility Contact: ,pq Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: Service Technician# <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: D40 License Number: 848150 <br /> Manufacturer Traiain¢ <br /> Manufacturer Com nen s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> FAIRM <br /> Cour sent Pass Fail <br /> Not Repairs Component Pass Fail Not <br /> Fo Tested Made Tested Made <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1K ❑ ❑ ❑ - ❑ ❑ ❑ ❑ <br /> a ,r ❑ I V ❑ ❑ ❑ ❑ ❑ ❑ <br /> I1 ❑ 1, IB/ ❑ ❑ ❑ ❑ ❑ ❑ <br /> r OC isr I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> of ❑ ❑ ❑ ❑ ❑ ❑ ,❑ <br /> 6 a ur ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> / ❑ Lei ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ El ElO <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 with legal requirements <br /> Technician's Signature: ��� -�� � Date: l��r� <br />