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Page I of 8 <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 appropriate pages of <br /> this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if applicable),should <br /> be provided to the facility owner/operator for submittal to the focal regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: IDate of Testing: <br /> Facility Address: <br /> Facility Contact: Perone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems <br /> Technician Conducting Test: <br /> Credentials: ®CSLB Licensed Contractor 17 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 880430 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass Fail Not T <br /> Component. Pass Fail Tested Made p Tested <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> LI ❑ ❑ ❑ ❑ ❑ EJ Li <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Ll <br /> ❑ ❑ :1❑ ❑ ❑ o ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Elo ❑ ❑ ❑ <br /> If hydrostatic testin 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, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />