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0 <br />SWRCB. Ianuazy 2002 Page _ Of <br />Secondary (Containment resting Report Form — Spill Buckets <br />This form is intended far use by contractors performing periodic testing oJ' U.ST 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 (ifapplicable), should be provided to the facility ownerloperaror for submittal to the local regulatory agency. <br />I. FACILITY INFORMATION <br />Facility Name: 777-0,v 70'.5W7 <br />soj ' Date of Testing. .7 <br />Facility Address: ✓`" <br />Facility Contact: 9q-11'rz <br />Phone: <br />Dare Kcal Agency Was Notified of Testing: <br />Name of Local Agency Inspector (ifpresent during testing): % <br />2. TESTING CONTRACTOR INFORMATION <br />Cony Name: Champion Precision Les .mg, Inc. <br />Technician Conducting Test: _ o <br />Credennate- X CSLB Licensed Conuactor C SWRCB Licensed Tank Tesler - <br />License Type: D-40 License Number: 804890 <br />Manufacturer Trainme <br />MmmafWturer Component(s) Date Tamm <br />3. SUMMARY OF TEST RESULTS <br />_®®ME <br />1=1 <br />MW <br />Q ■ <br />■ <br />_- <br />■ <br />001 <br />If hydrostatictesting was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAc`I RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the f tens stared in this document are accurate and in fall compliance with legal requiremems <br />Tecbntcian's Signature: _� Date: ' 05 <br />