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4 <br />SWRCR, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of ? <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages <br />of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: ,vim �n' <br />Date of Testing: e <br />Facility Address: 3o 1 <br />Facility Contact: <br />Phone: <br />Date Local Agency Was Notified of Testing. <br />Name of Local Agency Inspector if present during testin <br />Company Name: Stockton Service Station Equipment Co., Inc. <br />Technician Conducting Test: <br />Credentials: IX I CSLB Licensed Contractor SWRCB Licensed Tank Tester —� <br />License Type:. C -61/D40 HAZIHIC License Number: 309105 <br />Manufacturer <br />Manufacturer Training <br />3. SUMMARY OF TEST RESULTS <br />Date Train <br />Component <br />Pass <br />Fail <br />Not Repairs <br />Tested Mad;_Tested <br />Component <br />Pass <br />Fail <br />Not <br />Repairs <br />Made <br />C � <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 />Technician's Signature: Date: ���? <br />