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SWRCB,January 2002 Page of <br /> Secondary Conta rnent Testing.Report 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 /> Facility Name: 0OW--5 Date of Testing: <br /> Facility Address: 2®•722 W c5'S9- I`C9 A %) - IVAd7-t6A A 95"3 <br /> Facility Contact: IPhone: - 2-in - 76 75- <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING'CONTRACTOR INFORMATION: ' <br /> Com an Name: 14 F�c, 7A5.1S 7 <br /> Technician Conducting Test: Z-4-M6 <br /> Credentials: ❑CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Ty0e: ILicense Number: o /-/Z 7x <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training Expires . <br /> 3. SLMYLARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> LL ❑ ' ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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,th&Aacts state in this tent are accu4 ate and in full compliance with legal requirem its <br /> Date: <br /> Technician's Signature <br />