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SW <br /> RCB. January 2002 Page of <br /> Secondary Containment Testing.Report Form <br /> !'his form is intended for use by contractors performing periodic testing of UST secondary containment systems. t/se 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'applicahle), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: gL% Date of Testing: <br /> Facility Address: `f! AN.. <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector({f present during testing): X( 1 _ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Champion Precision Testing,Inc. <br /> Technician Conducting Test: Service Technician# — <br /> Credentials: X CSLB LicensedWContractor 1 a SWRCB Licensed Tank Tester <br /> License Type: D-40 License Number: 848150 <br /> Manufactures'Tr ainin� <br /> Manufacturer Com onent(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> ❑ ❑ ❑ 14 +. ❑ ❑ ❑ <br /> t� Lt ❑ ❑ u '� a� i ' ri ri F-1 <br /> d e ❑ ❑ ❑ e9 � [ i i l [ <br /> rr ❑ ED <br /> ❑ t,, � I:I l:l [�[ <br /> ❑ El .:.❑�. ❑ El ❑ <br /> it ❑ ❑ ❑ �' [ ] C.i l i i 1 <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 /> Technician's Signatur . Date: <br /> �2 = �a <br /> Z <br />