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SW[.i:B, January 2002 <br /> P __i__of <br /> Secondary Containment Testing Report Form <br /> 71iis fijrr�� is mcended for use by contractors performing periodic testing of UST secondary containment systems. Usa the <br /> el���r��l�riure pa,�e3 ol'•this form to report results for all componsnts tested. The cornpleted form, written test procedures, and <br /> pi-inlu Ills froiiz tests (f applicable), should be provided to the facility ownerloperator for submittal to the local regularary agency. <br /> 1. FACILITY INFORMATION <br /> -.scday Name: 5XI _ Date of Testing: <br /> facility Address: F02 0(W.4 <br /> Facitity Coacact: Phone; <br /> {l.)rxtt Local A6ency Was Notified ofTestiag : p — <br /> N4nw of local Agency Ins e4=rif resent dtiriU testi - <br /> 2. TESTING CONTRACTOR INFORMATION <br /> WCon1 do Name: <br /> 1'eclurlccan ConduCt�tg Fest: 1z,Y7 <br /> ('c-edentials: ig CSL$Licensed Contracror 0 S`WRCB Licensed Tank Tester + <br /> -License Type, License Number: 809850 <br /> NIalufasturer Training <br /> _ Manufacturer -Coi7aponenz(s) .^ Date Trninino Ex irp es <br /> INCONINCONTS—STS <br /> 3. SUMMARY Off" TEST RESULTS <br /> Component Pass fair Not Repairs Component Pass Fail Not Repairs <br /> Tested Mach I Tood Made <br /> ❑ ❑ ❑ ❑ 1 ❑ Q ❑ <br /> ❑ ❑ ❑ 0 fl ❑ Q ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ Q Cl <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> _ ❑ ❑ ❑ ❑ ❑ ❑ Q D <br /> 0 ❑ ❑ D ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ Q Q ❑ <br /> It hydrostatic testing was performed, describe what was done with the water after completion of tests; <br /> RECYCLE A D <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1'4) tiie best of n y knowledge, facts stated in this doCUMMI are accurate and InAU complta=with 1galt requlri;n=tr <br /> 'Fechaician's Signature; <br />