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r •( + r <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report For <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(tf applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> rDate <br /> y Names er; a � ;DVCeA ,r Date of Testing: <br /> y Address: r7 Op �,1NP <br /> y Contact: one: 20 Ll b$ — 1 q <br /> ocal Agency Was Notified of Testing: 23 Oz. <br /> Name of Local Agency Inspector(rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: 1- ]� 4fo1 v. Iate l e S —0\ <br /> Technician Conducting Test: .,, „) '• - <br /> icensCredentials: ❑C$LB Licensed Contractor WRCB Licensed Tank Tester <br /> License Type: vt l� aY License Number: O --1 8 2—.,—') <br /> Manufacturer Training <br /> Manufacturer Component(s). Date Training Expires <br /> 3• -SUAIMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs CNot Repairs <br /> Tested Made Component Pass Fail p <br /> � ❑ Tested Made <br /> ❑ ❑ ❑ 11 El C1,a El ❑ [Ell ❑ ❑ ❑ ❑ <br /> c cower ❑ ❑ ❑ ❑ ❑ p ❑ <br /> eco ❑ ❑ ❑ ❑ <br /> i !ti/ �- ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 12 <br /> 3X ❑ ❑ ❑ ❑ D ❑ ❑ <br /> 0 0 ❑ 0 <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 11 0 El <br /> ❑ 0i ❑ 11 ❑ ❑ MI hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> d ° <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,Phe facts stated in this docu n are accurate and in full compliance with legal requirements <br /> Technician's Signature: c <br /> Date:�,Z (� <br />