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SWRCB,January 2002 Page 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 far 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: "', 0 !` Date of Testing: — <br /> Facility Address: <br /> Facility Contact: s Phone: <br /> Date Local Agency Was tified of Testing: t L <br /> Name of Local Agency Inspector(f present during testing: <br /> 2. TESTING_ CONTRACTOR INFORMATION <br /> Company Name: S <br /> Technician Conducting Test; Gtlge <br /> Credentials: SLB Licensed ontractor ❑SV,/RCB Licensed Tank Tester <br /> License Type; License Number: <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Expires <br /> i 4 l� <br /> 3. SUMMARY OF TEST RESULTS <br /> C;om onent TPT,, F NTot Repairs Not Repairs <br /> pTested Made Component Pass Fail Tested Made <br /> i ❑ L] LL ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ L1 ❑ ❑ El Ll <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ o ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fads st in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: °-- - Date: <br />