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r <br /> 0 <br /> b <br /> S,WRCB,January 2002 s 1 e <br /> ty <br /> Page_o <br /> � _ p <br /> eeondary ontai meat Te ng rt Form <br /> This form is intended for use by contractors performing periodic testing of UST secondarycontainment systems: Use the <br /> appropriate pages of thisform,to report results.for all components;tester 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. FACHJTY INFORMATION <br /> FacilityName: {. _ . _. 7 Date ofTestixl : g/lip <br /> Facility Address: �, o <br /> Facility.Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> blame of Local Agency Inspector(fpresent during testing): l a, <br /> 2. TESTING CONTRACTQR INFORMATION <br /> .-Company, <br /> y <br /> Technician LAO <br /> Conducting Test: <br /> Credentials: CSLB Licensed Contractor -❑SWRCB-Licensed Tank Tester <br /> --- ---- censesype - — — Licer sg-Alu bryr, =— _..—---- --------- <br /> .. <br /> -- <br /> Tramani= _ <br /> ---- <br /> Manufacturer Component(s) Date TrainingE ires <br /> 3. SUMMARY OF TEST RESULTS <br /> rs <br /> Component Pass Fail- Not' Repairs] Component Bass Fail Not Repairs <br /> Tested' -Made Tested Made <br /> El El ' <br /> ❑ $ eC_ r p ❑ D <br /> _ ❑ ❑ .. ❑ iyyA ❑ ❑ <br /> El 01 0 1 <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1. 0 El D ❑ ❑ ❑ ❑ <br /> ❑ ❑ D ❑� ❑ Q ❑ <br /> El 10 0 El D <br /> ❑.__0,____ ❑ ❑ _ <br /> ❑ ❑ . ❑ ❑ ❑ ❑ ❑ ❑: . <br /> _. _❑.__._❑_ --fl. ---❑ -- - - - - - <br /> --- <br /> If-hydrostatic testing was performed,describe what was done with the water aftert completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge <br /> ted int ocu- t are accurate and in full e_oinpliance with legal requirements <br /> Technician's Signature: T_. <br /> Date: - <br />