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I arlG c V <br /> SWRCB, January 2002 <br /> Secondary ContAINment TeStin;'Rerort For <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use 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 applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> f� �� Date of Testing: to Ll <br /> Facility Name: �- -7 <br /> Facility Address: k'(/' 4 ! t Phone:: <br /> Facility Contact: J c°7 AJ <br /> Date Local Agency Was Notified of Testing: <br /> �G� ~ <br /> Name of Local Agency Inspector(tf present during testing): <br /> 2. TESTIN(;'CONTRACTOR INFORMATION: <br /> Com an Name: W l D ..g W <br /> Technician Conducting Test: \ B '� <br /> Credentials: ❑CSLB License Contractor WRCfl Licensed Tank Tester <br /> License Type:. License Number: q Z— `41 3 <br /> Jill Jill Manufacturer TrainlR9 <br /> Date Training Ex <br /> Manufacturer <br /> Com onerrt s ices . <br /> 3. SLUvEMLARY OF TEST RESULTS Not Repairs <br /> Not Re airsPass Fail <br /> Component Pass Fail Tested Made Component Tested Made <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> !� /� ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 <br /> 0 ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ 0 <br /> ❑ ❑----------------------- <br /> ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests <br /> t ,. 4z <br /> CERTIFICATION OF TECHNICLA.N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document erg accurate and in full compliance with legal requirements <br /> 41 <br /> f <br /> Date: <br /> Technician's Signature: : ' / l.° <br />