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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: L;,% - Date of Testing: 3 ' 2 '7 <br /> Facility Address: <br /> Facility Contact: Q� Phone: f? j 1 i� Y L-'r <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: ; C`h 2yC <br /> Credentials: CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: �_j icense Number- <br /> -- - <br /> Manufactarer Trainine <br /> Manufacwrer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST_ RESULTS <br /> Component Pass I F ' Not Repairs Tested Made Component Pass Fail Tested Repairs <br /> ale <br /> n ❑ ❑ <br /> F, C_ E 1 ❑ E ❑ iJ <br /> ..mow �,..�.�c j ❑ i ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ll- <br /> zp�r ❑ ❑ <br /> (l/� o'Z J ❑ _ ❑ ❑ ❑ L <br /> rSl� '1'i ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 s l' ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Qur^ <br /> tr— <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knmvledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> fill. <br /> rl It 7• ��� � { •✓ <br /> Technician's Signature: ALL F`�L—' �� � Date: 3 <br />