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0 <br /> iPage of <br /> SVdRCB,January 2002. <br /> Secondary Containment 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 /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> printouts.frorn tests(if app � ). <br /> 1. FACILITY INFORMATION <br /> Date of TestingM-5—Facilit Name:Facility Address: ZQ O ' Phone:�p — '373 <br /> Facility Contact: " <br /> Date Local Agency Was Notified of Testing: X S <br /> Name of Local Agency Inspector(iftduring testing): S"� o�+ca u� <br /> Lo- <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Com any Name: / <br /> Technician Conducting Test: rA Ca �OG <br /> redentials: CSLB Licensed Contractor ,tL'SWRCB Licensed Tank Tester <br /> C <br /> License Type: Z G License Number: S8 " <br /> UNNIVENIMM Manufacturer Training 4Date n Ex ires <br /> Manufacturer Component(s) <br /> 4 <br /> co 1-J <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> ate- ❑ ❑ ❑ ❑ ❑ O ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ D <br /> ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ .. <br /> ❑ ❑ ❑ ❑ ❑ D ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 knowledge,the acts stated in this document are ac trrate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br />