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SWRCB, January-1002 ': 4' :: c i�EN1_'��i <br /> t.. �P �_of <br /> Secondary ,C©ntainment Testing Rep©rt ° ?CT 3� PM �: 33 <br /> This form is irstertded for use 5y conrraciors performing periodic tes-zing of UST.secondwy contammenr systems Use the <br /> wpropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> prmmuzs from tests(f applicable), should be provided to the f wdity owner,'operator for suhmirtal to the local reguiatory agew,,, <br /> 1. FAC ATY IlYFORMATION <br /> Facility Name: 1. Daze of Testing: <br /> Facility-Address: ® e <br /> Facility Contact: a G� r Pbone: �o <br /> Date Local Agency Was Notified of Testing: q <br /> Name ofLocal Agency Inspector(if presenr dwW testing): <br /> 2 TESTING CONTILACTOR INFORMATION <br /> Company Name: Ch1 n ; �i-� <br /> Technician Conducting Test: <br /> Credentiais: X, CSLB Licensed Contractor Q SWO CR Lk=wd Tank Tester <br /> License Ty !e Q `�' License Number: <br /> MannfacgWer Training <br /> Component(s) Date T Expires <br /> 3. SUNO ARY OF TEST RESULTS <br /> Component i.Pass i Fafl riot haus Cam"neat Pass F 26 Not Repaws <br /> Tested Made 1 Tested .Made <br /> N i ❑ ❑ ❑ ❑ <br /> S � ( � I ❑ ❑ C ❑ ❑ ❑ ❑ <br /> r /AGI ❑ ❑ ❑ ❑ ❑ ❑ i i <br /> cl <br /> G I, ❑ C I L ❑ J <br /> i <br /> / G , ,- ❑ ❑ j ❑ L n <br /> F-1, <br /> ❑ <br /> 75 <br /> ❑ ❑ ❑ � ❑ ❑ ❑ <br /> if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> J <br /> CERTIFICATION OF TECEMCLUX RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge; the f acts.Mated in this document are accurate and in full camn/imwe with legal requirements <br /> T=unicwn;a Signature: Z Date: �0� �✓ <br />