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SWRCB, January 2002 Page of <br />Secondary Containment 'Testing Bort 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: �- r Date of Testing: ®o / <br />Facility Address: l / " V > <br />Phone: (pFacility Contact: ; t <br />Date Local Agency Was Notified of Testing: Z <br />Name of Local Agency Inspector (ifpresent during testing): ,,,P,r <br />2. TESTINGCONTRACTORINFORMATION: <br />Com anv Name: <br />Technician Conducting Test: / t0 A- .fir A/ p <br />Credentials: ❑ CSLB Licensed Contractor CB Licensed Tank Tester <br />License Type:. License Number: <br />Manufacturer Training <br />Manufacturer <br />. , Component <br />Component <br />no <br />no <br />Won <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,112e facts stated in this document are accurate and in full compliance with legal requirements <br />Date: <br />Technician's Signature: i <br />