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S'%'RCB, January:002 pie of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contracrors performing periodic testing of L'ST secondary con t m• Ud�e••the <br /> appropriate pages of this form to report results for all components tested The completed form;' 1t rvpr �d. 31671, <br /> printouts from tests(if applicable), should be provided to the facility owner.-operator for submittal to the local regulatory agencv. <br /> 1. FACILITY INFORMATION <br /> Facility Name: z, Date of Testing:41 j 3 <br /> Facility Address: � ot f <br /> Facility Contact: <br /> \\C. Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(tf present during testing): 71 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: _ , a y4: <br /> Credentials: CSLB Licensed Contractor SWR Licensed Tank Tester <br /> License Type: Llj'� j License Number. p <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMNLARY OF TEST RESULTS <br /> Component Pass Fail Tested Made Component Pass! F-1" Tested, Made <br /> 3 _Li ❑ IJu 'u <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ` ❑ ❑ I <br /> ❑ ❑ ❑ <br /> i <br /> I ❑ ❑ C ❑ <br /> If hydrostatic testing was performed, describe what was done with the water atter 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 accurate and in full compliance with legal requirements <br /> Technician's mature: / Date: <br /> ., r <br />