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SWRCB,January 2002 Page_a___of 10 <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 <br /> appropriate pages of this farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: �j Date of Testing: Z6–0,3 <br /> Facility Address: 3 co riTL4w E- w 05- , 7 7 <br /> Facility Contact: lv�k- I Phone; <br /> Date Local Agency Was Notified of Testing: '3 -18-03 <br /> Name of Local Agency Inspector(ifpresent during testing): rj t st r-- <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: A I g V-ro <br /> Credentials: CSL$Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A � �.(o � �4 D License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 5.-'#JE &)n ❑ ❑ ❑ PjjPj,.QZ ❑ ❑ ❑ <br /> r..r S d&111,2 ❑ ❑ ❑ 9 7 5 1 t'14pt,1 . Q ,tw BSc G ❑ ❑ <br /> ge <br /> atirr, 5d 11 El 11 <br /> _S Fi It Sv v>► & ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> - Z- <br /> U to C- <br /> G ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ❑ ❑ ❑ ❑ ❑ <br /> 11 X <br /> U b l ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> u 0 cr ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V 0 C ❑ G o ❑ ❑ I ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECEMCLAN RESPONSIBLE FOR CONDUCTING'TEIS TESTING <br /> To the best ofmy knowledge,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: X�'` Daze: 3— <br /> Costco#658 <br /> 3250 Grantfine & Hwy 205 <br /> Tracy, CA 95377 <br />