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SW1tCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed farm, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: D V . j Date of Testing: t f <br /> Facility Address: 'N49 <br /> Facility Contact: -C 5 Phone: <br /> Date Local Agency Was Notified of Testing It - <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: c <br /> Technician Conducting Test: �ee <br /> Credentials: X CSLB Licensed Contractor !l SWRCB Licensed Tank Tester <br /> License Type: \�1,\Q License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> _ 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> N ❑ ❑ El 11 ❑ Ll <br /> -42 5a me al" ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> 4-17 PW#JQ LkfL z' ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t L ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ 757 ❑ ❑ ❑ ❑ ❑ <br /> El, El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> t4�V O �;- d ak r tnelCs � r�CIC\. 1� 1 LtiZGA6 A � <br /> CERTIFICATION OF TECHNICLkN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: /J` Date: kV a✓i�t �Z- <br />