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rrs�c UL <br /> SW-RCB, January 2002 <br /> Secondary ContaNwAient Testing*Report Form,,e <br /> This form is intended for use by contractors performing periodic testing of LIST secondary containment systems. Use the <br /> appropriate pages of th ppl ablereport should be is fo l components te acility ownerloperat for submittal ttten lest o the local ocedures, and <br /> regulatory age7Tcy. <br /> printouts from !este(f applicable), provided <br /> i. FACILITY INFORMATION c <br /> _ � -- -- � Date of Testing - Z <br /> Facili010 <br /> ty Name: t�1 <br /> Facility Address: q _ <br /> ' Phone: 2. 0\� <br /> Facility Contact: <br /> Date Local Agency Was Notified of Testing: Ij t �, 7 <br /> Name of Local Agency Inspector(if present during testing): 3(\.) ` �. &0 R <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com an Name: VT <br /> Technician Conducting Test: Lu k f t,3 <br /> Credentials: ❑CSLB Licensed Contractor H„SWRCB Licensed Tank Tester <br /> License Type:. License.Numb�er: CA I L4- .� �J <br /> 1Vlanttiacturer Trainin <br /> Manufacturer <br /> Comvo"­ffc!1 Date Trainine Expires <br /> • 3. btTv1vlitzOr TEST RESULTS <br /> Not Repairs Not Repairs <br /> Pass Fail Component Pass Fail Tested Made <br /> Component <br /> Tested Made <br /> El 11 13 D <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> k ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Cl <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> a ❑ ❑ I ❑ <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 hest of my knowledge,the facts stated in this document are accuf ate rn con:piiance with ieaal requfrennents <br /> Date: <br /> Technician' Signature: <br /> Technician's Sign <br />