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.SWRCB, January 2002 <br />Page of <br />Secondary Containment 'Testintn <br />g 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 farm 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 />Date of Testing: <br />Facility Name: <br />Facility Address: <br />Facility Contact: .�? N� v? J Phone: <br />Date Local Agency Was ITotified of Testing: -","%'y—Dzi <br />Name of Local Agency Inspector (rfpresent during testing): /7'--,-v (" <br />2. TESTING'CONTRACTOR INFORMATION: <br />Company Name: <br />Technician Conducting Test: V `,P- ,/' r ,* <br />Credentials: ❑ CSLB Licensed Contractor p�RCB Licensed Tank Tester <br />e:. License N <br />License Typumber: ' -' d <br />Manufacturer Training <br />Manufacturer Component(s)Date Training Ex ices . <br />_,. . ntr r -an nrlmoT D VQT.ii TC <br />Component <br />Component <br />mom= <br />000n <br />oor�t� <br />mom= <br />mom= <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />V1 9-. 1 .n <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: Date: <br />