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, <br /> 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 form 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: j J Date of Testing: , '-7 `O ` <br /> Facility Address: /3 �rLti ,LQ C fx <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 INFORMATION <br /> Company Name: <br /> Technician Conducting Test: �' G Ln r Jr <br /> Credentials: 3R CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: `�`��� License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Tr ' Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass F ' Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ItIlf-lale / C ❑ 0 ❑ ❑ ❑ <br /> y _ 'j ❑ ❑ ❑ <br /> �..y ✓I/;�7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> U -,;z- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 El 11 <br /> �Sll✓tel�°� ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knawledge, the�Jfacts stated inthisdocument are curate and in full compliance with legal requirements <br /> Technician's Signature: / /-7`,�t �[/��1 �' Date:✓ ✓r��- ey <br />