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• Page of <br /> SWRCB, January 2002 <br /> . nment Testing deport Form <br /> Secondary Contai1 containment systems. Use the <br /> This form is intended for use by contractors performing periodic testing of UST y <br /> a ro riate pages of this form to report results for all components c'li tested.e The <br /> fotr submittal tto the local regulatory agency. <br /> PP P .f �' <br /> printouts from tests(f applicable), should be provided to <br /> 1. FACILITY INFORMATION <br /> � Date of Testing: <br /> PDateLocal <br /> me: fit, `e <br /> dress: LI 1/0 C ! Phone:. <br /> ntact: <br /> Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tf present during testing): �f� <br /> 2. TESTING CONTRACTOR MORMATION <br /> a `TU /o 7307` n a G• <br /> ► r�. i a c- <br /> Company Name: i L` v� <br /> Technician Conducting Test: � -e DI i CB Licensed Tank Tester <br /> Credentials: ❑CSLB Licensed Contractor <br /> License Number: <br /> License Type: <br /> Manufacturer Training Date Train Ex ires . <br /> Com onent s <br /> Manufacturer <br /> `,� OF TES P.ESTLTS <br /> • 'j' S� -� Pass Fail Not Repairs <br /> ' <br /> Not Repairs Component Tested Made <br /> Component Pass <br /> Fa* Made ❑ ❑ <br /> El ❑ <br /> i^f� •I1 V/ IJP ❑ ❑ 11 El <br /> 11N El <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 11 ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> h drostatic testing was performed,describe what was done with the water after completion of tests: <br /> If y '�.....�* <br /> ESTING <br /> CERTIFICATION OF TECHNICIAN RESPONSI acE1rFOR n inf ll compliance with legal requirements <br /> To the best of my knowledge, the facts stated in this document are <br /> ate <br /> Date: <br /> Technician's Signature: <br />