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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 farm, 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 /> Facility Name: ZfL,,Lj1e I Date of Testing: I d-it -d,I <br /> Facility Address: 7S6 ITS r te. ef-A+ <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Nam of Local Agency Inspector Cf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: —7o�7i—zAtz --43K 7.-4�fk ;!� IAI<-- <br /> Technician Conducting Test: ' rAS <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Tm <br /> Aming Expires <br /> 3.---SUMMARY OF TEST RESULTS <br /> Component Pus Fad Not Repairs Component Pass Fad Not Repairs <br /> Tested Made Tested Made <br /> 0 11 0 n 11 <br /> El El C] El El <br /> A e re 4- F7,7/e/ 11 El 0 El 11 El El <br /> Uj El El 0 El 11 11 11 <br /> 11 El 0 D 11 El El El <br /> 0 0 11 El El El El 11 <br /> 11 11 El El 11 El El 0 <br /> 11 El El El El El El 0- <br /> 11 El 0 El El <br /> 11 El [1 0 El El El Ell <br /> 11 El El El 11 E, El Ej <br /> 11 El 1 11 El ❑ 11, 11 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> L--l'--7'—o— ' IA,- SO '9'" <br /> CERTIFICATION OF TECIINICLAW RESPONSIBLE FOR CONDUCTING TIM TESTING <br /> To the best of my knmWedge,the facts stated in this document are accurate and in full compfiance with legal requirements <br /> Technician's Signature: Date:_ <br />