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$,WRCB, January 2002 • • 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 farm to report resarlts for all components tested The completed form, written test procedures, and <br /> c <br /> printouts from tests(f applicable), should be provided to the facility owner/operatorfor submittal to the local regulatorya en <br /> I. y. <br /> FACILITY INFORMATION <br /> Date of Testing: /O - 0,/'� V <br /> Facility Name: <br /> Facility Address: g� a pvn t °' a`vt <br /> Phone: �� CJ l 7 2— <br /> Facility Contact: _ <br /> Date Local Agency Was Notified of Testing : a <br /> Name of Local Agency Inspector((present during testing]: <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com anv Name: <br /> Technician Conducting Test: ' ) /P p• r r) <br /> CB Licens <br /> Credentials: ❑CSLB Licensed Contractor ed Tank Tester <br /> Q T// � <br /> License Type:. <br /> License Number: <br /> Manufacturer Training Date Training Expires <br /> . <br /> Manufacturer Component(s) <br /> 3. SUTvIlV1AFY' OP TEST RESULTS Not Repairs <br /> Pass Fail Not Repairs Component Pass Fail Tested Made <br /> Component Tested Made <br /> �°- ---- <br /> & ❑ ❑ ❑ ❑ <br /> Oil <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ Cl ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> I.9 fY {P t_1 P , c V7 '5-2 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefacts stated in this document are accufate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature:44 <br />