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SWRCB,January 2002 Page I of <br /> Secondary Conta ent Testing'Report Forn* <br /> Tliis 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: Date of Testing: <br /> Facility Address:-7 Q 01 95231 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Wti&dbif Testing: 03 <br /> Name of Local Agency Inspector(rfpresent during testing): U0 <br /> 2. TESTINO'CONTRACTOR INFORMATION: <br /> Com an Name: n ZLQRL�a <br /> Technician Conducting Test: (_ 1 a MAA <br /> Credentials: ❑CSLB Licensed Contractor WSWRCB Licensed Tank Tester <br /> License Type:. �:� License Number: 4'1 1 LA 3 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUAMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> 'T'ested Made Tested Made <br /> iRu cif-+ ❑ . ❑ 1 ❑ 1 ❑ <br /> ❑ 1 ❑ ❑ ❑ <br /> ❑ 10 ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ell A-- <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledb e,the facts stated in this document are accurate and in full compliance with legal requirements <br /> h <br /> Technician's Signature: �1 g �G� � f Date:` --_ <br />