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SWRCB,,lanuary 2002 Page of <br /> Secondary Containment Testing Report Form <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: (,, Date of Testing: j' 30, rp-L <br /> Facility Address: 2,5 -k, t qa 1 c-&, <br /> Facility Contact: sd J I Ph6ne: .;,3 — f" <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): l,SJ�OAJOIJJ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: , —A:�7S Gu\ lei <br /> Technician Conducting Test: -k-- L <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: 12�0L�eCD License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Rr ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ [I ❑ " ❑ ❑ <br /> E. ] ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ �! ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> qi4-Uo Ccs-,\7MED w F ac d ntI c A 2C, <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> I dTechnician's Signature: Date: yC�T 2 d Z-- <br />