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Page of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingslomr�onents todic ested.ed. The completng of UST ed fora niy tawrittent test procedures,and <br /> appropriate pages of this form to report result f comp <br /> on <br /> from tests (if applicable), should be provided to the.facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> _ Date of Testing: C <br /> Facility Name: pInspector <br /> Facility Address: phone: " �,Facility Contact: <br /> Date Local Agencd of Test ng <br /> Name of Local Agency (if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION -- <br /> Company Name: 1 <br /> Technician Conducting Test: _. 0 r ❑SWRCB Licensed Tank Tester <br /> Credentials: ❑CSLB Licensed Contractor License Number: <br /> License Type d 2 <br /> Manufacturer Trainin <br /> Date Training Ex fires <br /> Manufacturer <br /> Component(s) <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Component Pass Fair <br /> Not Repairs Component Pass Fail Tested Made <br /> Tested Made n ❑ <br /> Cl <br /> ° ❑ ❑ ❑ ❑ u" ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 7 ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ Lj <br /> ❑ ❑ El <br /> El El El El ❑ ❑ ❑ <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 facts stated in this document are accurate and in full compliance with legal re's;° arrents <br /> f <br /> Date:---!() <br /> Technician's Signature: <br />