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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 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: .y� '-'d p[ Date of Testing: 271,�,� <br />Facility Address:.-"`, <br />Facility Contact: F-F.tA ( Phone: <br />Date Local Agency Was Notified of Testing: -3 a, 0 <br />Name of Local Agency Inspector (tf present during testing): <br />2. TESTING' CONTRACTOR INFORMATION <br />Com an Name: <br />Technician Conducting Test: k t <br />Credentials: 0 CSLB Licensed Contractor WRCB Licensed Tank Tester <br />License Type:. License Number: <br />Manufacturer Training <br />Manufacturer Com onent s Date Training Ex ices . <br />— <br />Co mponent <br />Cdmponent <br />■■��® <br />am �win <br />MEJIM <br />MMMEME000v <br />OMMOMONME <br />oo <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICLA.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in ficll compliance with legal requirements <br />Technician's Signatures' <br />Date: '�+ <br />