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FEB.25.2003 9:41RM SCOTT CO NO.607 P.2i11 <br /> $NVRCB,January 2002 Page—of— <br /> Secondary Containment Testing Report Form <br /> hisform is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> Qappropriate pages of this form tc reporr results for all components tested The completed form, rrirten test procedures• and <br /> printoutsfrom tests (If applicable), should be provided to rhefacility owner/operatorfor submittal to the local regularory agency. <br /> I. FACILITY INFORMIATION <br /> Facility Name: Date of Tesrin <br /> Facility Address: Lin <br /> Facility ContacC Phone: <br /> Dete Local Agency Was Notified of Testing <br /> Name of Local Agency inspector(if present during sestina): ,�7 p 7' <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name: <br /> Technician Conducting Test: n Ce► Mn+ <br /> Credentials: CSLB Licensed Contractor S SWRCB Licensed Tank Tester s <br /> License Type: A ,9 ,G , L 5L Ll 60 License Number: ag-1 t s <br /> Manufacturer Training <br /> Manufacturer Com oneat s Date Training, 'res <br /> t' <br /> s <br /> 3. SUMMARY OF TEST RESULTS <br /> tCom onent Pass Fail Not Repairs Component Pays Fail Not Repairs <br /> p Tested Made Tested I Made <br /> ,t 1�nrti\G.f <br /> LAO <br /> VDs;. �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 best ofnq,knowledge, the f acts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's SignatureDate: I L-'?n—(7Z <br /> ep, <br />