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SWRCB,January 2002 1J <br /> Secondary Containment Testing Report Fo <br /> Thisform is intended for use by contractors performing periodic testing or UST secondary containmen .y e . se th and <br /> appropriate pages of this form to report results for all components tested The completed fo ry agency. <br /> printouts from tests(rf'applicable), should be provided to the facility owner/operator for submi r <br /> 1. FACILITY INFORMATION <br /> Date of Testing: <br /> Facility Name: 5c,-,t t14 i � !� <br /> Facility Address: op t ' <br /> Phone: fc--7 <br /> Facility Contact: _.5— <br /> Date Local Agency Was Notified of Testing: Z (-3U <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ? i �. <br /> Technician Conducting Test: , `c7t T7n <br /> WRCB Licensed Tank Tester <br /> Credentials: ❑CSLB Licensed ontractor I � <br /> License Type:" te�t� t� License Number: -� L#�Z —fit <br /> Manufacturer Training Date Training Expires <br /> Manufacturer component(s) <br /> 3. SUMMARY OF TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made ❑ <br /> wu t�✓7 c� ❑ ❑ 0 0 ❑ 0 ❑ <br /> e�uu d ct ❑ a 0❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ° ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ a ❑ <br /> ❑ 7F-0 <br /> ❑ ❑ 0 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: ` <br /> C!�B d e "t('4 <br /> Cd E' ! d <br /> VIA <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE re jaccur FOR nCONDUCTING THIS <br /> TESTING <br /> EST I N quirements <br /> To the best of my knowledge,the facts stated in this do ent <br /> ® Date:_ <br /> Technician's Signature j <br />