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SWRCH, January 2002 <br />Page __ of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of USY'secondary containment systems. Use the <br />appropriate pages of thisftrot to report results for all components tested. the completed forret, written test procedures, and <br />printouts from re3�ro(if applicable). should be provided to the facility ownerloperatorJor submittal to the local regulatory agency. <br />Y. FACTUTVINFORMATirnN <br />Facility Name: ,!>i "` ,, �. �.�r Date of Te <br />Facility Address: <br />Facility Contact: <br />Datc Local Agency Was Notified of Testing: <br />Name of Local Agency fnspactnr (ifpPe5ent during teviing): <br />2. TESTING CONTIZACTOR WFORMATION <br />Company Name: CPT /EPIC Compiance Sys. <br />'Technician Conducting Test; Keith A Huston Service Technician#5262044UT <br />Credctitials: X CSLJ3 -Licensed Contractor 11 SWRCB Licensed Tank Tester <br />License Type; D-40 License Number: 880430 <br />Manufacturer <br />3. STJN4MA'Jk'Y OF TEST RV,%T1T,TS <br />Date <br />Component <br />pass <br />Fail:Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />WI <br />Not <br />rested <br />Rtpairs <br />M49dp <br />'—] <br />Ll <br />f <br />c <br />r 5'�'%aD <br />Ile <br />I/ <br />F7 <br />Li <br />Lj <br />Q <br />El <br />0 <br />......❑.......... <br />0 <br />Ll <br />17 <br />11 <br />0 <br />0 <br />0 <br />El <br />El <br />13 <br />11 <br />L <br />11 <br />Li <br />1:1 <br />L <br />Ej <br />11 <br />El <br />Cl <br />❑ <br />E7 <br />E: <br />L <br />11 <br />0 <br />11 <br />0 <br />El <br />[I <br />El <br />1.1 <br />0 <br />El <br />❑ <br />0 <br />E <br />0 <br />►r <br />El <br />0 <br />1: <br />0 <br />C <br />[J., <br />o <br />0 <br />-if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONOUCTING THIS TESTING <br />To the best of trzy knowledge, the facts stated in this document are accaPate and injuli complianee with legal requ iremefttv <br />Technician's Signaturt--t 4 2 9 <br />Dal <br />VO 30Vd 3A83SAIMA Z90ZZE860Z Vz:T0 800Z/91/90 <br />