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,. ! i <br />SWRCB, January.2002 FINAL DRAFT <br />Page I of 7 <br />Secondary Containment Testing Report Form <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 repot: results for cl' components tested The completedform,' <br />test procedures, and <br />printoutsfrom tests (if applicable), sho:lobe provide,: to the facility owner/operatorforsubmittal to tre local regulatory agency. <br />FACILITY INFORMATION <br />FacilityName: ogLj%.,) pr /yjlDate ofTestino: pt/ <br />- d <br />Facility A. ,::ess: g 4�i UJ �d CLF, S3? -1 <br />Facility Contact: 0 lW Phone. 7 7 _ 8 <br />zs <br />Date Local Agency was Notified of Testing: <br />Name of Local Agency Inspector (tf fre;ent during testing): � <br />2. TESTING CO -N -TRACTOR INFORMaTTON <br />Company Name: C / /O/f� <br />�G%S O/✓ /�.� %/ <br />Technician Conducting Test: <br />PEK <br />Credentials: 'CSLB Licensed Contractor <br />❑ S WRCB Licensed Tank Tester <br />License Type:License <br />Nwnber: <br />Manufacturer Compor.e-: <br />Dlanufacturer Trainino <br />Date Training Expires <br />❑I <br />❑ <br />❑aEQ <br />❑ <br />-5UMP el <br />_❑ <br />3. SUMMARY OF TEST RESULTS <br />Component-Pass�Fail <br />Not <br />Tested <br />(Repairs <br />I Dlade <br />Component Pass <br />Fail <br />Tested Not, <br />Tested <br />Repairs' <br />blade 1 <br />-?l <br />❑I <br />❑ <br />❑aEQ <br />❑ <br />-5UMP el <br />_❑ <br />I <br />❑I <br />❑ <br />!❑❑ <br />1 <br />sew <br />❑ <br />❑ <br />❑ <br />❑ <br />❑0 <br />I ❑ <br />❑ <br />❑n❑ <br />❑I <br />❑ <br />❑❑ <br />t?f <br />EJ <br />❑ <br />1 ❑ <br />❑ <br />❑I❑ <br />❑ <br />❑u <br />- ..---- -�.t_p <br />, 101 <br />Ell <br />I <br />❑ <br />❑ <br />❑ <br />n Q❑ <br />❑I <br />❑ <br />j❑❑I❑ <br />❑ <br />p gcO_ I❑ <br />❑ I <br />❑ <br />❑ <br />❑I❑ <br />I <br />❑ <br />I PSS- ❑ I <br />❑ <br />C! <br />❑ <br />❑ <br />❑ <br />1 ❑ 10 <br />�jI❑ <br />❑ 1 <br />❑ <br />❑ I <br />❑I❑ <br />I <br />❑ <br />Comments — If hydrostatic testing �; as performed. describe what was done With the water after ceripletion of test(s). <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the fir, -u stated in this document are accurate and in full compliance nzth legal requirements. <br />Technician's Nance (Please Print). <br />i cctnician's Sienature: A64-4. <br />Date: N� OZ <br />