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e <br /> WRCB,January 2002 Page—L 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 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 /> FacilityName: t Date of Testing: _Z p <br /> Facility Address: I Octp ,vh' <br /> Facility Contact: Phone:�, <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector('(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: A <br /> Technician Conducting Test: I ,C G 56zl <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> i <br /> i <br /> �a <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> i ❑ ❑ ❑ ❑ 0 0 ❑ <br /> id D 11 D ❑ ❑ ❑SIP ❑ <br /> T <br /> id <br /> 1 ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ 1 ❑ <br /> i r ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ 0 0 ❑ <br /> ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> -Cs -C 1 -18 ❑ ❑ ❑ ❑ D ❑ D <br /> ❑ ❑ El <br /> 0 El0 ❑. <br /> ❑ ❑ ❑ 11 ❑ 0 ❑ 0 .. <br /> ❑ 0 0 ❑ 0 ❑ D ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Qy 11 n © Q cf,�t►111 M�-� <br /> i <br /> 1 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature "N. Date: <br />