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SWRCB,January 2002 rage i or ti.. <br /> Secondary Contailtent Testinb'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 ow►zer/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ob r14 Date of Testing: // 1-1 <br /> Facility Address: ` j.0 ® C d <br /> Facility Contact: fiat- Phone: -6 ( <br /> Date Local Agency Was Notified of Testing !1 02, 05 <br /> Name of Local Agency Inspector((present during testing): <br /> 2. TESTING'CONIRACTORINFORMATION: <br /> Com an Name: -- <br /> Technician <br /> Technician Conducting Test: i rye ryl <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:. License Number: <br /> Qj <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3.—S ' Y®F TESTREST,J�,TS <br /> p Not Repairs <br /> Component Pass Fail ,nested Repairs <br /> Component Pass Fail Tested Made <br /> G--'P ❑ . ❑ ❑ ❑ <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 /> -� (N16 7 (f&tW7 Ad 14 kJKY-7 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,th f cis sta ed in it Is_document are accurate and in full compliance with legal requirements <br /> Technician's Signature: r " Date: <br />