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0 <br /> Page of <br /> ,WRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This form is intended,for use by contractors performing or allomponents tested.ing TheThse completed formsecondary awrraten test procedures,and <br /> tems. Usethe <br /> appropriate pages of this farm to p f regulatory agency.printouts from tests(if applicable),should be provided to the facility owner/operatorJor submittal to the local re lato a en <br /> I. FACILITY INFORMATION <br /> 6 .Z Date of Testing: — •t� <br /> Facili Name: L f <br /> Facility Addrrss:` c Phone: S— <br /> r <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: Vi0 <br /> Name of local Agency Inspector(tfpresent during testing: p <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: <br /> Technician Conducting Test: <br /> Q M e o.cJ <br /> CSLB Licensed Contractor 13'SWRCB Licensed Tank Tester <br /> Credentials: License Number: — U <br /> License Type: z G—/® <br /> Manufacturer'Trainine Date Training Ex fres <br /> Manufacturer Com onent(s <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail .nested Made <br /> Component Tested Made <br /> f It V/_ ^�`. ti .0 ❑ ❑ 0 0 0 ❑ <br /> til C1i 0 ❑ 0 ❑ ❑ 0 ❑ <br /> 0 0 ❑ O ' ❑ ❑ ❑ <br /> 0 0 0 0 ❑ ❑ ❑ 0 <br /> ❑ O ❑ 0 <br /> ❑ ❑ ❑ <br /> 0 0 0 0 0 <br /> o ❑ O ❑ ❑ <br /> 0 ❑ <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 facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br />