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SWRCB, January 2002 1 arQ <br /> Secondary Conta0hent T'eSting*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(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: —/ <br /> Facility Name: �® <br /> Facility Address: ' <br /> Facility Contact: Phone: <br /> Date Local Agency Was�-Nofified�s�fin <br /> Name of Local Agency Inspector(if present during testing): ; <br /> 2. TESTING'CONTRACTOR INFORMATION: <br /> Com an Name: <br /> Technician Conducting Test• (> <br /> Credentials: ❑CSLB Li ensed Contractor WRCB Licensed Tank Tester <br /> License Type:. License Number: - //t/ <br /> Manufacturer Training <br /> Manufacturer Comr)o-­(sN Date Training Expires . <br /> 3. SUAMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail p Component Pass Fail Tested Made <br /> Tested Made <br /> �f ❑ ❑ ❑ ❑ <br /> 5 t � ❑ ❑ ❑ ❑ <br /> �� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,_describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSI L FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document a a urate and in full compliance with legal requirements <br /> -� .. Date: <br /> Technician's Signature: �' ' <br />