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FROM :B.Z.SER VICESTATION MAIN NCE FAX NO. :916 371 2540 an. 28 2005 09:28AM P11 <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use bycontractorsper rrnh <br /> .fo igperiodic testing of USTsecondary containment systems. Use the <br /> appropriate pages of this forst to report resuftsfor all components tested, The completed form, written rest procedures,and <br /> Printoutsfrom tests ffapplicable),should be provider!to the facility omerloperatorfor submittal to the local regulatory agency, <br /> .1. AC ATX INFORMATION <br /> Facility Name: An &I J Date of Testing, 1-2 <br /> _-7 <br /> Facility Address. <br /> Facility Contact. A4, none: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector Wpresant during tesfing), <br /> 2. TE9TINC,CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: <br /> Credentials: C1 CSLB Licensed Contractor 0 SWRCR Licensed Tank Tester <br /> License TYpe-.-.. License Number; <br /> lqanufactumllra-i—nin-& <br /> Manufacturer Component(s) <br /> Date Traijiing.Expirc% <br /> 3. SUMMARY OF TEST RESULTS <br /> Not <br /> Component Pass Fill I Not Repairs Corlponent Pass Fail Rep2lrs <br /> 1.rested Made Tested Made <br /> D <br /> cl 0 <br /> D 0 El ❑ <br /> 0 El 0 0 <br /> El 0 0 0 0 0 <br /> D El <br /> El ❑ <br /> n 0 <br /> FO 13 'El 11 El . 13 <br /> El 0 E) 11 Ci 0 El0 <br /> 0. 0 .1 C1 0 <br /> ❑ <br /> El C) 1 [3 [1, ❑ El C1 Q <br /> E) <br /> If hydrostatic testing was performcd,describe what was done with the water After completion of tests: <br /> PIA <br /> CERTIFI !ION 0 TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> stated <br /> 't <br /> Tothe,bestofirrykno edgethefa- stated In this document are accurate and in frill compliance with legal reqtirgItzents <br /> tu <br /> Technician's Signa Date: <br />