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SWRCB, January 2002 <br />• <br />Page; of <br />Secondary Containment Vesting 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 report results far all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should he provided to the facility owner,ioperatar for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION.. <br />Company Name: , ort 7-i^lk c <br />Technician Conducting Test: C , i< <br />Credentials: ❑ CSLB Licensed Contractor - C SWRCB Licensed Tank Tester <br />License Typie:. <br />License Number: <br />Manufacturer Training <br />Manufacturer Com oneut(s) Date Training E <br />RY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />I- a.�t fl 72 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TITS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full cumplianee with legal requirements <br />�` � <br />'t'echnician's Signature: . Date: 7 <br />KIM <br />M <br />00 <br />�r�000 <br />oo�Q <br />�ra�000° <br />a©oo <br />v • <br />. <br />o <br />MW <br />©©D©! <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />I- a.�t fl 72 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TITS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full cumplianee with legal requirements <br />�` � <br />'t'echnician's Signature: . Date: 7 <br />