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_ • Page_of <br /> SWRCB,January 2002 ort Form <br /> Secondary Containment Testing Report USTsecondmy containment systems. Use the <br /> This form is intended for use by contractors performing periodic testing of <br /> arm to report results for all components tested The completed form, written test procedures, an <br /> appropriate pages of this f should u provided to the facility oxner/operator for submittal to the local regulatory age��ay <br /> printouts from tests(if applicable), TION <br /> 1. FACILITY INFORMA pate of Testing: e ' 4 b <br /> �(J 6!' L/l i X99 P - <br /> Facility Name: 7 L"'P, 2A� D • <br /> Facility Address: 1 0 Phone: <br /> Facility Contact: ' <br /> Date Local Agency Was Notified of Testing: testin 5-r flfc �7 H I <br /> Name of Local Agency Inspector(I present during P� <br /> 2. TESTING'CONTRA <br /> CTOR FORMATION <br /> Com anvName: ,mrno <br /> Technician Conducting Test: thrRCB Licensed Tank Tester <br /> Credentials: ❑CSL B Licensed Contractor r ense;Number'. <br /> License Type: Manufacturer Trainin Date TT in Ex ties . <br /> Com onerrt s <br /> Manufacturer <br /> vt1VIA Y OF TEST RESPass <br /> SULTS Not Repairs <br /> S <br /> �. , Fail Tested Made <br /> Not Repairs Component <br /> Pass Fail Tested Made ❑ ❑ ❑ ❑ <br /> Component ❑ ❑ <br /> 8� ❑ ❑ ❑ ❑ <br /> �, ❑ ❑ ❑ ❑ <br /> I ❑ ❑ ❑ ❑ <br /> 9i P tr ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> water after completion of tests: <br /> performed,describe what was done with the <br /> If hydrostatic testing was P 5 rZt� <br /> �12,ttiwt <br /> RESPONSIBLE FOR CONDUCTING TRIS TESTINe requirements <br /> CERTIFICATION OF TECHNICIAN <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with leg R / <br /> d ` <br /> Date: t <br /> Technician's Signature: <br />