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T <br /> SWRCB, January 2002 Page of <br /> Secondary Containment Testing Deport Form <br /> This for-nt 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> n Date of Testing: ,3 O ' <br /> FacilityName: Z /� <br /> r <br /> Facility Address: rj G t. �� <br /> Facility Contact: /e,l' <br /> o 5 Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(rf present during testing): E' <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: °� E <br /> Technician Conducting Test: � i X CSN A d� <br /> Credentials: ❑CSLB Licensed Contractor �XSWRCB Licensed Tank Tester <br /> -------------- <br /> License Type: . License Number: <br /> Manufacturer Training Date Training Expires . <br /> Manufacturer Component(s) <br /> 3, SUrvlTVfiA1Vj( OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> ❑ . ❑ ❑ ❑ <br /> 5 �< < U cl�� ❑ ❑ ❑ ❑ <br /> 1 <br /> t r I 1 =19 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El El <br /> �� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 kno►Pled( the facts stated in the document are accurate and in full compliance with legal requirements <br /> c�'jv '^+ Date: . <br /> /9 <br /> Technician's Signature: /z <br />