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Mar 02- 10 10: 13a Elite TV Contactors 12094616342 p. 2 <br /> 06/03/2004 07:58 209468a r lr in r-L- -- <br /> SWRCB,7amtary 2002 Page—L of <br /> Secondary Containment Testing Report Form <br /> This form is interufed far use by contractors performing periodic lesting of UST secondary container systems. Use rhe <br /> appropriate pages of chis form to repor•r re=lfs-for all componenu tested. 1'l a completed form, written test procedrues.and <br /> printouts;from tests(rf applicable),should be provided to rhe facility owner/operator-for submitral to the Ioca!regulatory agency. <br /> L FACILITY INFORMATION <br /> Facility Name: F— Date of Testin — <br /> Facility Address: ' ` ` <br /> Facility Contact: Phone: •C - - <br /> Date Local Agency Was Notified of Tasting: I- --t v <br /> Name of Local Agency Inspector(if present during resting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 7 <br /> Technician Conducting Test: <br /> Credentials: 0 CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type: License Number; <br /> Manufacturer Training <br /> M�^ faeturer Cc:;t "neat';) Tate Training!Expires <br /> i d <br /> Tr 0; �� _ — <br /> 3. SUMMARY OF TEST RESL7L.TS <br /> Component Pass Fail Not Repairs Component Pass Fail Not 11"in <br /> Tested Msde Tested Mode <br /> 87 SPici_ ;C�. �_� u ❑ a D ❑ ❑ o k <br /> ❑ ❑ ❑ ❑ o ❑ ❑ ❑ <br /> ❑ o ❑ ❑ C o ❑ ❑ <br /> D C ❑ d 0 0 D 0 <br /> ❑ ❑ 0 ❑ D ❑ D ❑ <br /> G ❑ ❑ 0 ❑ 0 D ❑ <br /> D 0 ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ O O __ _ ❑ 0 0 n <br /> o ❑ 1 ❑ D ❑ D ❑ D <br /> ❑ I D Q ❑ 0 0 ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTJFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To lne best of my knowledge,thefacts staled in/this document are accuraie and in fall compliance wfth legal rngairernents <br /> /' <br /> Technician's Si;rtaWre -=iU ./Jci{� � L `l 5 - l C <br /> Date:_- <br /> F <br />