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S WRCB,January 2002 Page of 2 <br /> Secondary Containment Testing Report Form <br /> Thisform is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to thefaciliry owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facili Name: 0e.4cev\ J69F Date ofTesting: qlt t)1 <br /> Facility Address: IS3 F )yam/ aic S <br /> Facility Contact: �T' ecu h LC ' Phone: <br /> Date Local.A¢ency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): - <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: t„f <br /> e' njfaT— <br /> Technician Conducting Test: �—�-- <br /> Ci•edentials: ®-CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: ,¢ /1 L Q i^� License Number: 93 M <br /> _Manufacturer Trainine <br /> Manufacturer Components Date T raL'ning Expires <br /> 1'-j C 0 1 Le rc <br /> SSZ s- .2.r p — <br /> 3. SUMMARY OF TEST RESULTS <br /> Component (Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested I Made I Tested Made <br /> I box ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> tel ❑ ❑ ❑ i ❑ ❑ ❑ ❑ <br /> I ❑ ❑ j ❑ ❑ ❑ ❑ ❑ I ❑ <br /> ❑ ❑ED ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i I ❑ ❑ 11C1I ❑ ❑ C1 10 <br /> ❑ ❑ ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ <br /> ! ! � 11 ❑ FI ❑ 1 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water aftle_r completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the face stated in this <br /> /document are accurate and in full compliance with legal requirements <br /> Technician's Signature:_ /r/�tt�K� Date: <br />