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SWRCB, January 2002 Page t of �- <br />Secondary Contai ent Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />r 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 />Testin <br />Facility Name: �4 1z r ,. g <br />Date of D <br />-- 1 <br />Facility Address: 7"006� r n' <br />Facility Contact: -", ( hone:(` � Z (4 — <br />Date Local Agency Was Notified of Testing: 0 l -Q3 O Lo <br />Name of Local Agency Inspector (tf present during testing): <br />2. TESTING* CONTRACTOR INFORMATION: <br />Company Name: <br />Technician Conducting Test: <br />Credentials: D CSLB Licensed Contractor �CB Licensed Tank Tester <br />License Type:. License Number: <br />Manufacturer Training <br />Manufacturer Com onetrt s Date Training Ex ires . <br />- , ,r 1 TST d -%IM TTi QT ®TOUT T4Z <br />Component <br />Component <br />M��'©��' <br />MIMM <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 />Date: <br />Technician's Signature: <br />r <br />i' <br />