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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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FAC INFORMATION <br /> Facility Name: , Date of Testing: ®./ <br /> Facility Address: d fo <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: e,,,eq1e19 42 r` <br /> Technician Conducting Test: e ,S <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component pass Fail Not Repairs Component Pass Fait Not Repairs <br /> Tested Made Tested 'Made <br /> 6c 1 ❑ ❑ ❑ ❑ 0 ❑ <br /> z ❑ o ❑ ❑ o ❑ <br /> ❑ 0 0 ❑ o ❑ 0 <br /> 0 ❑ 1 ❑ ❑ 0 0 ❑ ❑ <br /> 0 0 0 ❑ ❑ ❑ 0 ❑ <br /> ❑ 0 0 ❑ D 0 0 <br /> ❑ ❑ ❑ ❑ ❑ 1 0 0 ❑ <br /> 0 ❑ 0 0 ❑ ❑ 0 ❑ <br /> 0 ❑ ❑ 0 0 ❑ 0 0 <br /> 0 ❑ 0 0 ❑ 0 0 ❑ <br /> 0 0 ❑ ❑ ❑ ❑ 0 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: 4 r '<j Date: 40 <br />