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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 LIST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(cf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> r <br /> acility Name: ct esra 3b�rc� DateofTesting: �- !'Ka5acility Address: /�3 //� �'�C,acility Contact: Phone:ZO 9 <br /> Date Local Agency Was Notified of Testing : —4�- -0,5' <br /> Name of Local Agency Inspector(if present during testingJ: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: '?-t i r_ Coc l \j <br /> Technician Conducting Test: F,0 h,,t <br /> Credentials: OCSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: „4 L License Number:69 3 d <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Traiuing Expires <br /> h <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ®' ❑ ❑ ❑ Q ❑ ❑ ❑ <br /> mss - ❑ ❑ ❑ ❑ . ❑ ❑ ❑ <br /> n U rr Ce - ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> t_U ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> U ❑ ❑ ❑ ❑ Q ❑ ❑ <br /> S�G6��xt s g ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S« 4 ❑ ❑ ❑ ❑ ❑ o ❑ <br /> ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> i'rr` `0 e CIA <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: `f r <br />