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S WRCB, January 2002 <br />Page of <br />Secondary Containment Testing Rep_ off-Alk.1i 06 <br />Th/s form Is Intended for use by contractors performing periodic testing of (IST secon T <br />appropriate pages of this form to report results for all components tested The complete <br />ir''�l�ms Use the <br />printouts from tests (lfappllcable), should be provided to thefacility owner/operator for submittal to the local �regulato aaden <br />I. FACILITY INFORMATION n' agency. <br />ffLooalAggen:cy <br />: Sk Cwt �. 0p c c: <br />Date of Testing: <br />Facilityss;. D � ����S�vbt; - <br />y -a G (A ✓1 Ph3ency Was Notified of Testing: (o p(� Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name; <br />Technician Conducting Test: —L�5 e , F <br />fir• <br />Credentials:' � O CSLB License Contractor <br />WRC$ Licensed Tank Tester <br />License Type; z:.cm. lc_ "j �5�-c r License Number; <br />D�tl2� <br />_Man, ___ufacturer Training <br />Manufacturer Com onent s <br />Ante Training rm;rae <br />CERTIFICATION OF TECHNICIAN RE PONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge cts stated In this d u ent are accurate and 1,u full compliance with. legal requirements <br />Teclwician's Signature �l <br />w� Date, <br />5� c- <br />SU1VMARY OF TEST RESULTS <br />Component <br />Pass FellNot <br />Repairs <br />COmporent <br />iii? c/ Gt y �L 1 <br />Z <br />0 <br />Tested <br />0 <br />Made <br />Pass <br />Fall <br />Not <br />Tented <br />Repair; <br />ado <br />❑ <br />.Q 0: <br />0 <br />El <br />0 <br />u i#L <br />❑ ❑ ❑ <br />❑ <br />0 <br />L] <br />0 <br />.- ��. �,,d <br />0 ❑ ❑ <br />0 <br />0 <br />❑ <br />❑ <br />i Z <br />0 ❑ 0 <br />❑ <br />0 <br />D <br />El <br />0 0❑ <br />❑ <br />0 <br />❑ <br />O <br />sr <br />0 0 ❑ <br />0 <br />0. <br />❑ <br />❑ <br />IA( 0 <br />❑ <br />p <br />0 <br />❑ . <br />❑ <br />❑ ❑ <br />-7t8 <br />D <br />❑. <br />❑ <br />❑ <br />0 [7 0 C]° <br />0 <br />0 <br />0 <br />D 0 0 ❑ <br />° <br />° <br />❑ <br />D <br />If hydrostatic testing was performed, describe what was done with the water after <br />0 <br />❑ <br />d <br />❑ <br />com Teti <br />r �n •f tcsts; <br />1.4 f c4 e 1.4 <br />A.1 <br />CERTIFICATION OF TECHNICIAN RE PONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge cts stated In this d u ent are accurate and 1,u full compliance with. legal requirements <br />Teclwician's Signature �l <br />w� Date, <br />5� c- <br />