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SWRCB, January 2002 Page of <br /> Secondary Contain Ment 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 form 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 agel7cy. <br /> 1. FACILITY INFORMATION _ <br /> Facility Name: , �dZ-�G u��v�`Z l�fa! L t � Date of Testing: Os <br /> Facility Address: t g 1-ie erjj 6,t S( o -1G7�%�"- -�l 9`� �' <br /> Facility Contact: Phone: 1�0 1�-7 93-7 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Comnan Name: r ;- <br /> Technician Conducting Test: A V� 1 mA ,,U , / <br /> Credentials: ❑CSLB Licensed Contractor ASWRCB Licensed Tank Tester <br /> License Type:. Lfcense.Number: 0��- <br /> Manufacturer Traininc <br /> Manufacturer Component(s)) Date Training Expires <br /> 3. SUMMILARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Z <br /> s <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, t/ae acts stated in this document are accurate and in fill compliance with legal requirements <br /> Technician's Signature: { Date: <br />