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SWRCB, 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 farm to report results for all components tested The completed form, 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 /> Facility Name: d Date of Testing:Q 7 - 3 <br /> Facility Address: f �' �� /_ `, <br /> Facility Contact: \ Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR L iFORMATION <br /> CompanyName: E S,ceS� -T GL ��L 12 S��i-) <br /> Technician Conducting Test: _�_ ,, / d- - �, G� <br /> Credentials: CSLB Licensed Contractor F1, SWR Licensed Tank Tester <br /> License Type: 1L``�j' License Number: p <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMIYURY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made ;Tested Made <br /> 3 C ❑ ' ❑ ❑ ❑ ❑ 1 C <br /> I13, ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑ ❑ � C 0. 1 - <br /> 0 0 100 ❑ C ❑ <br /> 0 0 ❑ ❑ ❑ ❑ 1 <br /> ❑ ❑ ❑ C ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ - <br /> ❑ 0 0 ; C ❑ ❑ ; C <br /> ❑ ❑ ❑ C <br /> ❑ ❑ ❑ C ❑ 0 - <br /> ❑ ❑ ❑ C 0 ❑ C <br /> I ❑ ❑ ❑ _i JG ❑ G <br /> If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br /> r <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: eq, Date: d d <br />