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SWRCB, January 2002 Page Of <br />A1 7h <br />Secondary Containment Testing Repoif-TWwwrF <br />This form is intended for use by contractors testing of Wsecolr ziThM Use the <br />completed <br />0 <br />appropriate pages oj <br />f this form to report results for all components tested nw 4 litid o dures, and <br />printouts from tests (if applicable), should be provided to the facility ownerIpperatorfor submittal to the local regulatory agency. <br />I W A vn.rry Mvn-um A TMN <br />Facility Name: / <br />r- v Date of Testing: Y <br />Facility Address: <br />Facility Contact: <br />Phone: <br />Date Local Agency Wa:, Notified of Testing <br />Name of Local Agency Inspector (if present during testing}: <br />C -- <br />Company On a=:2a <br />Paas <br />Pass, <br />Fail <br />Technician Conducting Test: <br />ell <br />Fag <br />Credentials: ;R CSLB Licensed Contractor <br />VSWRCB Licensed Tank Tester <br />rT-, <br />License Type: <br />Manufacturer <br />License Number: <br />himufaeftrer Training <br />Component(s) <br />Date Training Expires <br />Lj <br />17 L, <br />El <br />11 <br />11 <br />--I <br />3- RITMMARV OF IrF.I.RT RRP41TITS <br />Component <br />Paas <br />Pass, <br />Fail <br />Not Repairs Component' <br />Tested Made <br />Pass <br />Fag <br />Not <br />Tested <br />Repairs <br />Made <br />L-// 77 C <br />Lj <br />17 L, <br />El <br />11 <br />11 <br />--I <br />®r <br />0 <br />0 <br />Lj <br />11 <br />11 <br />El 71 <br />o <br />C3 <br />0 03 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />0 D,❑ <br />El <br />Fj <br />11 <br />El <br />0 <br />❑ <br />L7 <br />L L01 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in faff compliance with legal requirements <br />Date; <br />Signature: Technician's S <br />