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SWkCB,January 2002 1.r _ Page of <br /> Secondary Containment Testing'Report Form `001 <br /> This form is intended for use by contractors performing periodic testing of UST 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: her r ��✓ �� 1— ri �y C3� Date of Testing: — — 0 <br /> Facility Address: 1" k °l v a e. ;' C <br /> v qop _ •t/ <br /> Facility Contact: � Phone.) <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency inspector(ifpresent during testing): TT <br /> 2. TESTING CONTRACTOR INFORMATION- <br /> Corn anv Name: <br /> Technician Conducting Test: [Vu VAc� <br /> Credentials: ®CSLB Licensed ontractor RCB Licensed Tank Tester <br /> License Type:, License.Nurnber: i—//'l` <br /> Manufacturer Train in <br /> Manufacturer Com anent{s Date Training Expires . <br /> 3. . SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> ComponentPass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> t� tf ❑ ❑ Cl ❑ <br /> r � ❑ C] ❑ <br /> D ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ <br /> ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> I h tY'�•D '4� 1 � � 1 , t.? Lt`f't} t1i '�'Da'r t-;"cY- ©P7 ? <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 /> ��_•. Date: `'�'�`� <br /> Technician's Signature: '" <br />