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SWRCB, January 2002 <br />Secondary Containment Testing Report Form w <br />This form is intended for use by contractors performing periodic testing of U.ST secondary containment systems. U.s&'Mk 27 2009 <br />appropriate pages of this form to report results,for all components tested. The completed form, written test proc rp, and <br />printouts from tests (iij'applicable), should be provided to the facility owner/operator for submittal to the local rVI) b � HEALTH <br />�CEpVlCE� <br />1. FACILITY INFORMATION , PE`��P„ <br />Facility Name: 1A 7py C,t,Wq-.� '( ra <br />Date of Testing: ZZ <br />Facility Address: W 04S4 C� e,V �'Y �cr ` �)C �'- :? i <br />9 e <br />Facility Contact:,5 w q�-ot. V1 e) to V.0,VN Phone: <br />('?e? <br />Date Local Agency Was Notified of Testing: 5 ZZ v <br />License Type: I(w� K, --J:: 5 } V <br />Name of Local Agency Inspector (ufpresent during testing): <br />Manufacturer <br />2., TESTING CONTRACTOR INFORMATION <br />Company Name: ( L— ' i (uc. -a, <br />—r, r v` <br />Technician Conducting Test:. <br />Not <br />Tested <br />Repairs <br />Made <br />Credentials ❑ CSLB Licensedtontractor <br />WRCB Licensed Tank Tester <br />License Type: I(w� K, --J:: 5 } V <br />License Number: <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ ❑ <br />SCc�� dad ► 2.R. <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not Repairs <br />Tested Made <br />rr <br />d'J ur u.t (,,e lett e- <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ ❑ <br />SCc�� dad ► 2.R. <br />❑ <br />D <br />❑ <br />❑ <br />D <br />❑ ❑ <br />5e< < 1.Q. -�t2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />r 04A a, 1, ,4� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />t2- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />Lid .AlI., <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />42 t <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />F3 <br />11 <br />Ll <br />I]❑ <br />F--)❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />p 4 -.-(ht iA styI.;i)h0,1-in, (.sehq/�����.,t�/t"���,r.:���:—&se<� <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this jk!, ument are accurate and In full compliance with legal requirements <br />Technicians Signatur : ; ! <, __ Date:�Q�_ <br />SS0A <br />