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SWRCB, January 2002 Page of <br /> Secondary Containment 'Testing Deport 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 completed farm, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: !0 ; / 6 4! <br /> Facility Name: 0 , _< < i D'= �= <br /> Facility Address: ) I !�. <br /> Phone: — .30 <br /> Facility Contact: p,{ <br /> Date Local Agency Was otified of Testing : 1 3 L� <br /> Name of Local Agency Inspector(ifpresent during testing): S r n_ 1 ,A �:✓ �� <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comoanv Name: — _ <br /> U <br /> Technician Conducting Test: 1,e /� t ��� !.'-`� - ---5`" 'l <br /> Credentials: ❑CSLB Licensed Contractor , <br /> WRCB Licensed Tank Tester <br /> ---i' <br /> License Type:. <br /> Licensember:.Nuj - ( `� <br /> Manufacturer Training Date Training <br /> Manufacturer <br /> Com onent(s <br /> 3. SUryB AI j OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> ❑ ❑ ❑ <br /> D El D <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ rD <br /> El <br /> El El El El <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RE,SPO�'dSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledg e, the facts stated in this documei are ac urate and infull compliance with legal requirements <br /> :� <br /> Technician's Signature: r / Date: / <br />