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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 GST secondary containment systems. Use the <br /> appropriate pages of this form to report results fir all components tested The completed fornt, written test procedures, and <br /> printouts from tests(if applicable), should he provided to the facility owner•operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORNUMON <br /> Facility Name: cs Date of Testing:el <br /> Facility Address: SA76i fi..y I. <br /> Facility Contact: \ < I Phone: <br /> Date Local Agency Was Notified of Testing : l 4- <br /> Name <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFOR-NL-kTION <br /> Company Name: 'a <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor SvVRCfi Licensed Tank Taster <br /> License Type: L ``\Ae)C\D License Number: p <br /> Manufacturer Trainins <br /> ?Manufacturer Component(3) Date Training Expires <br /> 3. SL-MALA RY OF TEST RESULTS <br /> ( Not Repairs I Not Repairs <br /> ! <br /> Component Pass Fail I Tested Made Component Pass Fail i Tested I, Made <br /> • � � i I J ' � I — <br /> I — i <br /> — <br /> I ❑ j ; ❑ C ❑ ❑ f - 77 <br /> ❑ I .� r I � C � I - <br /> 77 <br /> � 1 :J � <br /> - I 7 <br /> ❑ ❑ I <br /> 1 r �; I ❑ I u J <br /> )f 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 Signature: <br /> `�= �� Date: 95�') 7 <br />