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SWRCB, January 2002 <br />Page % of J— <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 TA!''TT TTV TIVVnU M ATTnN <br />Facility Name: ,�Lrp +. 3 / 3 Date of Testing: d Z d o <br />Facility Address: ;t_570 m Sid <br />Facility Contact: Y✓1 — ti Phone: cf' _ <br />Date Local Agency Was Notified of Tes g : <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Banks & Co <br />Technician Conducting Test: Adolfo Rivas/Danilo Baez/Carlos Alderete <br />Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: Jaz. License Number:383550 <br />Manufacturer Training <br />71ncon <br />cturer Component(s) Date Training Expires <br />TS -STS Sump Tester UST <br />---------------------o/Owens <br />A.O. Smith/Ameron FRP--"-----"---" <br />APT/Total Flexible Piping --"--"--------------- <br />Containment <br />QFT1%4'N/TADV nT''TTiCT RF.RITI,TS <br />Component <br />v v `. <br />Pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />T 7 De i"au a/ 5 �vu <br />Pot <br />8 -7 t9dauc A Biu <br /># - Z <br />q I o �laaulwr s <br />3-el <br />14 Q,1 <br />.� P, c <br />de#meg <br />+� <br />S .z •e�+ �i 0-3 <br />-e 1W y <br />✓ <br />s o P., % s <br />'R 7 06&rer 6? <br />���IUSI tliyeJ �' rit k' <br />If hydrostatic testing was performed, describe what was done with the water atter completion or tests: <br />. <br />F1 - w F 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: C/�C� "` f Date: 1 I�O Z <br />