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SWRCB, January 20020 1 , * Page I 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name:' <br />Facility Address: <br />Facility Contact: <br />Date Local Agency Was Notified of <br />Name of Local Agency Inspector (if) <br />2. TESTING CONTRACTOR INFORMATION <br />3//9/0 <br />during testing <br />Date of Testing: <br />Technician Conducting Test: Zq / i tea <br />Credentials: O CSLB Licensed Contractor WRCB Licensed Tank Tester <br />License Type:. License Number: ! <br />Manufacturer Trafnin� <br />Manufacturer Component(s) Date Training Ex fres . <br />� w • , ,Vr C%Va rrvorr nvci.TT Te <br />r <br />r <br />Component <br />M <br />Not <br />mom_ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />4- s s 1 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts slated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: - N �'"r°`" �` w Date: J �� <br />