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SWRCB, January 2002 Page of <br /> Secondary Containment Vesting 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 /> 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: ,,t Al Date of Testing: <br /> Facility Address:33p® 6-r -z c az.°C o,,3 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : l 1 2 q 0 5 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION: ' <br /> Company Name: <br /> Technician conducting Test: t <br /> Credentials: ❑CSLB Licensed Contractor VSWRCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer COMDO­_+(sl Date Training Expires . <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail 'T'ested Made Component Pass Fail Tested Made <br /> SP t ❑ . ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Sp i ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑LEE ❑ ❑ ❑ <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 knowledb e,the acts stated in tit is document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature. <br />