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9WRCB,January 2002 Page- —of 7 <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 thisform 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 /> Facility Name: rS a o_k Date of Testing:IZ-I <br /> Facility Address: 10 Ct <br /> Facility Contact: Phone: O - �a <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(i(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 7, 9\ <br /> Technician Conducting Test. `, I-C,-C f <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> MOVIE <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Trainin Expires <br /> f <br /> r <br /> 1 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass Fail Not Repairs <br /> Component Pass Fail Tested Made p Tested Mede <br /> C.1 ❑ ❑ ❑ ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ rE01 <br /> El Cl <br /> `Z _ w ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑. <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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[egad requirements <br /> Date: <br /> Technician's Signature. <br /> i <br />