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Page / ot=1. <br /> S WRCB, January 2002 <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 farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> �� v, ?2 r Date of Testing: 75 <br /> Facility Name: /9S' - v 9 t7 <br /> Facility Address: al/y /- "tCK f phone: --,�rOv t <br /> Facility Contact: NCtc i <br /> Ds <br /> Date Local Agency Was Notitied of Testing : J �G��� <br /> Name of Local Agency Inspector(ifpresent during testing]: JO ti <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comnanv Name: S V <br /> Technician Conducting Test: L t 16 l 1 ft9 n p Ufii It <br /> Credentials: ❑CSLB Licensed Contractor VSWRCB Licensed Tank Tester <br /> License Type:. License Number: q 7 // y <br /> Manufacturer Training <br /> Manufacturer <br /> Component(s) Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Re airsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 7f '/ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 1 ❑ <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 accu4ate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />