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SWRCB, January 2002 <br />u� <br />Secondary Contaient 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 regulatozy agency. <br />1. FACILITY INFORMATION <br />Facility Name: Date of Testing:" <br />Facility Address:' <br />'' Phone: � — -� <br />Facility Contact: �, _ <br />Date Local Agency Was Notified of Testing: /11 <br />Name of Local Agency Inspector (rfpresent during testing): <br />1 CTmXA4A VV nrd TMIR® RF,, T II, C ,4; <br />Component Ism <br />Component <br />momma <br />t�t�tto <br />MMM <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />r S, a <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accuS ate and in full compliance with legal requirements <br />f <br />Technician's Signature: 61�' x'� Date: <br />P <br />