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tsar 211 12 08:37a <br />SWRCB, January 2002 <br />E 1 i teV Contactors 120941342 <br />p.}2 <br />Paget of <br />Secondary Containment Testing Rep in Form <br />This form is intended for use by contractors performing periodic testing of UST secon, lc 7: containment systems., Use the <br />appropriate pages 'ofthis form to report results' for all components tested The comply it 1 form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operatory5i submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: (1� &-fff <br />Facility Address: <br />Facility Contact: Phone: _ <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rfpresent during testing,): <br />2_ TESTFNG CONTRACTOR TNFORMATIO14 <br />Company. Name: Z <br />o <br />:Technician Conducting Test:. <br />— <br />Credentials:. CSI B Licensed Contractor <br />❑ SWRCB Licensed T.•ir. <br />License Type. • . 1 a <br />Manufacturer <br />License Number . <br />Manufacturer Trainin <br />Component(s) <br />im, <br />[fir,Ll— <br />1 <br />If hydrostatic testing was performed, describe whatwas done with the water after comple d( i. of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUt ING THIS TESTING <br />To the best of my 75nowledge, the facts staled in this document are accurate and. in full ci jcpliance with legal requirements . <br />Technician's Signature: Dater <br />EM <br />im, <br />rim= <br />o <br />mom <br />nomm, <br />�000 <br />mom <br />00MM <br />�Q�raa <br />If hydrostatic testing was performed, describe whatwas done with the water after comple d( i. of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUt ING THIS TESTING <br />To the best of my 75nowledge, the facts staled in this document are accurate and. in full ci jcpliance with legal requirements . <br />Technician's Signature: Dater <br />