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V <br />Page <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />This firm, is intended for• Ilse ht° connectors per:%rmir►g�onents tested. � <br />sted.l c , j <br />Tirnpletedforinvr,itten test prroced u�es, and <br />appr•opriatc 1)(19(!S• of this form to report results fol- all orrrr/ <br />printouts from tests (if 'app lic able), should he provided to the facility owner/operator for submittal to the local regrdator v agency. <br />7vc' 7 i. FACILITY INFORMATION <br />—7Fateof "Testing: " Ltd <br />Facility Name: ---____- <br />Facility Address: f_ phone: <br />Facility Contact: <br />Date Local regency Was Notified of Testing: <br />Name of Local Agency Inspector (if �present du►•ing testing): <br />2. TESTING <br />Company Name: K e y til c eu ``L <br />Technician >a Conducting Test: <br />Cred f' CSLB Licensed Contractor <br />License Type: <br />Manufacturer <br />WRCB Licensed Tank Tester <br />-�-License Number: �r�1 <br />Manufacturer Traidn-9 <br />3. SUMMARY OF TEST RESULTS <br />----_ -- Not Repairs Component <br />Component Pass Fail rested Made <br />rl ii <br />f 1 <br />what was done with the water after completion of tests: <br />if hydrostatic testing was performed, describe <br />Date <br />Not Repairs <br />Pass Fail Tested Made <br />F] <br />CERTIFICATION <br />I <br />1 <br />I j <br />CER'T'IFICATION OF TECHNICIAN RESPONSIBLE T,OIt CONDIIC'TINC TIIIS T H rrrents <br />To the best of'nrp knowledge, he facts stated it, this document are accurate and in full compliance with 1, <br />•�' - <br />Date: - <br />'Technician's Signa <br />uue: <br />_'` _ <br />