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'SWRCB,January 2002 rage or <br /> .Secondary Contai ent Testing*Report For <br /> This fore: 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. FACILITY INFORMATION <br /> Facility Name: g r . r V W, .,q Date of Testing: <br /> Facility Address: 7©,9D AI r 04 cr �, �, <br /> Facility Contact: Phone: <br /> 9 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): (,v e <br /> 2. TESTINO'CONTRACTOR INFORMATION: <br /> Comparry Name: <br /> Technician Conducting Test: _�/' Ala r <br /> Credentials: ❑CSLB Licensed Contractor CB Licensed Tank Tester <br /> License Type:. License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SUWdARY OF TEST RESULTS <br /> Not Re airsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ . ❑ ❑ ❑ <br /> r�. ❑ ❑ ❑ 0 <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> ❑ 0 ❑ 0 <br /> ❑ 0 0 ❑ <br /> ❑ 0 ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> ❑ 0 0 ❑ <br /> 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 /> r� <br /> C;e� 2 --\ <br /> Technician's Signature: <br /> Date: a_. <br />