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SWRCB, January 2002 Page of <br /> Secondary Conti ent Testinb'Report For^ <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 /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: e421.z,I i P� - / f? Date of Testing: =~ -2-61,06— <br /> Facility Address: � , f < cr ' <br /> Facility Contact: .e Phone: <br /> Date Local Agency Was Notified of Testing: Q <br /> Name of Local Agency Inspector(ifpresent during testing): C' -r, <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> CompanX Name: <br /> Technician Conducting Test: f-e Q, JV ' V,1 t i- <br /> Credentials: ❑CSLB Licensed Contractor RCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Ex ices . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs <br /> Component p Pass Fail Tested RMades Component Pass Fail Tested Made <br /> FU C `� ❑ ❑ 11 ❑ <br /> r 11 ❑ ❑ ❑ ❑ <br /> ct <br /> z xt ❑ ❑ ❑ ❑ <br /> tr ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> k..l . <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 /> Technician's Signature: Date: <br /> }' <br /> W. . <br />