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SWRCB,January 2002 Page of <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 lest 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: Ar Qt Date of Testing: —C7 <br /> Facility Address: a- 3o <br /> Facility Contact. Phone :- <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): d3 <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test: v PA^0 s� <br /> Credentials: D CSLB Licensed Contractor SWRCH Licensed Tank Tester <br /> License Type: I License Number: -2'-'r A4 <br /> 11 Manufacturer Training <br /> Manufacturer Comonent s Date TrainingExpires . <br /> 3. SUMMARIVOF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> l r® ❑ ❑ ❑ ❑ <br /> tt <br /> 7.7 ❑ ❑ ❑ ❑ <br /> rt ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 requirements <br /> Technicians Signature: <br />