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SWRCB,January 2002 Page / of <br /> Secondary Containment Testing Report Form �J <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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: <br /> Facility Name: a <br /> Facility Address: <br /> Facility Contact: Phone: 3 cj <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency inspector(if present during testing): <br /> 2. TESTING*CONTRACTOR INFORMATION; <br /> Company Name: ' <br /> Technician Conducting Test:„Z— 1 <br /> Credentials: [7 CSLB Licensed Contractor SWR.CB Licensed Tank Tester <br /> License Type:. License Number: <br /> 11 Ell Manufacturer Training <br /> Manufacturer <br /> Com onent s Date Training Expires . <br /> 3. SLUvEVIARY OF TEST RESULTS <br /> Not Repairs Pass Fail Not Repairs <br /> Pass Fail p Component Tested Made <br /> Component Tested Made <br /> ❑ . ❑ ❑ ❑ <br /> T1100 ❑❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATIO TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my Irnowledg II is stated in this cunt are'"acc� ate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signatur . P <br />