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SWRCII, January 2(102 Page of <br />Secondary Containment Testing Report Form <br />This form is inIA4d d for use by contractors performing periodic testing of IM'secondary containment systems. Use the <br />appropriate pages r/'thisform to report resul�or all components testi L The completed form, written test procedures, and <br />printouts• from tests (if applicable), should 8e pr�"vrdedta'the facitiry owriedopehator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: -1 1 Date of Testing: ti <br />Facility Address: :3s2� *% - <br />Facility Contact: ]tone: <br />Date Local Agency Was Notified of Testing: <br />Name of Lj •( Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company'Narne: Cbampion Precision Testing, Inc. <br />Technician Conducting -Test: — <br />Credentials: X CSLB Licensed Contractor 1 ❑ SWRCB Licensed Tank Tester <br />Licew Type: D40 License Number: <br />Manufacturer Tt ainine <br />tdlnufacturer Com nent(s) Date7Yainin E fres <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing 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 kmoiPledge, thefa�stated in t/tis document are accurate and in full compliatwe with legal requirements <br />Technician's Signature:, Date: --Q <br />1� <br />© C D <br />_ u - _ <br />000 <br />y0■�0 <br />• _ : <br />�0�� <br />000 <br />Gt�]©t7 <br />pppp <br />If hydrostatic testing 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 kmoiPledge, thefa�stated in t/tis document are accurate and in full compliatwe with legal requirements <br />Technician's Signature:, Date: --Q <br />1� <br />